Madison Baptist Church Child Participation And Medical Release Form (Page 2 of 2) in pdf

Madison Baptist Church Child Participation And Medical Release Form Page 2

City:

__________________________ State: ________ Zip:

_________

Health Insurer: _________________________________

Phone: ___________________

Policy No:

__________________________

Date of last tetanus shot:

__________________________

Release

In consideration for allowing Child to participate in Church events and activities, Parent/Guardian hereby

forever releases Church, including any of its staff, volunteers and members, from any and all claims of

any nature whatsoever arising in any way out of Child’s participation in Church activities, except to the

extent caused by the gross negligence or intentional, willful or illegal actions of Church staff, volunteers,

members or other participants. Nothing contained herein is intended to release any health care providers

who are not Church staff, volunteers or members from any liability.

Duration

This Agreement shall be in full force and effect from the date executed below for so long as Child

participates in Church activities.

SWORN to and subscribed before me

this ____ day of _____________________, 2015.

____________________________________

_____________________________________

NOTARY PUBLIC

Parent: (sign)

My Commission Expires:

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Madison Baptist Church Child Participation And Medical Release Form Page 2