Medical Release And Liability Form - Texas printable pdf download

Medical Release and Liability Form

Central Texas Conference Young People’s Ministries Events

Name of Participant__________________________________________________________________________________

Name of Legal Guardian/s ___________________________________________________________________________

Address, City, State, Zip ______________________________________________________________________________

Home Phone (________) _________________________ Work/Cell Phone (_______) _____________________________

Age__________ Birthday ______________________ School ________________________________________________

E-mail___________________________________________________________ Date of Last Tetanus Shot _____________

Functions and Activities

I understand that participating in programs, recreation and other activities of Central Texas Conference of the United

Methodist Church is a privilege. Prior to my participation in such activities, I acknowledge that there are certain risks

associated with these activities, including, by way of example, physical injury due to activity-related accidents, physical

injury due to transportation-related accidents, illness or even death. In addition, I acknowledge that there may be other

risks inherent in these activities of which I may not be presently aware.

Release of Liability

By signing this Permission and Waiver Form, I expressly warrant that this child named above or I, if I am a participant, am

capable of withstanding both the physical and mental demands of these activities. I also expressly assume all risks to the

child or me participating in the activities, whether such risks are known or unknown to me at this time. I further release the

church and its ministers, leaders, employees, volunteers and agents from any claim that my child may have or that I may

against them as a result of injury or illness incurred during the course of participation in these activities. This release of

liability is also intended to cover all claims that members of the child’s or my family or estate, heirs, representatives or

assigns may have against the church or its ministers, leaders, employees, volunteers, or agents. I further agree to indemnify

and hold harmless the church and its ministers, leaders, employees, volunteers, or agents from any and all claims arising

from my participation in its activities and programs, or as a result of injury or illness of my child during such activities.

Media Release (please initial)

________ I authorize Central Texas Conference of the United Methodist Church to publish my name and/or photograph on

a website or in print media.

Sleeping Arrangements

Everyone will sleep in cabins at Glen Lake Camp. Participants will be divided by gender and assigned to cabins by

churches. Ratio will continue to be maintained in each cabin, with at least two non-related adults of the same gender in

each cabin. Participants will sleep in individual twin size bunk beds. Participants should bring a pillow and sleeping

bag/sheets and blankets for individual use.

First Aid and Emergency Medical Treatment

I recognize that there may be occasions where the child named above or I, if I am a participant, may be in need of first

aid or emergency medical treatment as a result of an accident, illness, or other health condition or injury. I do hereby give

permission for agents of the church to seek and secure any needed medical attention or treatment for the child named

above or me, if I am a participant, including hospitalization, if in the agent’s opinion such need arises. In doing so, I agree

to pay all fees and costs arising from this action to obtain medical treatment. I give permission for attending physician(s)

and other medical personnel to administer any needed medical treatment, including surgery and, again, I agree to pay for

the medical treatment. I also agree to let the hospital or medical agent release the child or myself back to the church

representative after treatment.

Insurance information

Carrier ________________________________________________ Policy Number _______________________________

Policy Holder Name ______________________________________ Carrier Phone Number ________________________

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Medical Release And Liability Form - Texas

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