Medical Waiver/release Form (Page 2 of 3) in pdf

Medical Power of Attorney and Release

I, ______________________________________, hereby acknowledge under oath that I am the parent or guardian of

_________________________________ (“my child”), and, unless I otherwise state in writing, I hereby give permission for my

child to participate in events and activities conducted, sponsored, and/or organized by the Youth Ministries Office of the Georgia

Baptist Convention. As an integral part of such permission, I recognize that the Georgia Baptist Convention is a nonprofit

organization whose purpose is to share the Gospel of Jesus Christ and is not in the business of providing entertainment events and

activities for youth.

Therefore, I hereby agree to hold the Georgia Baptist Convention, including the Youth Ministries office, its employees,

representatives and agents, harmless from and against any and all claims, demands, liabilities, actions, causes of action, damages

and/or expenses, of any nature and kind and without limitation, arising from personal injuries to my child or property damage,

either resulting directly or indirectly from my child’s participation in the Youth Ministries’ youth programs. I hereby

acknowledge that I assume the risk of any and all personal injury or property damage that may occur to my child, that I will hold

the Georgia Baptist Convention/Youth Ministries Office completely and totally harmless concerning any such injury or damage,

that I hereby waive any cause of action or right to cause of action that I might have against the Georgia Baptist Convention/Youth

Ministries Office or that might thereafter accrue as a result of such injury or damage, and that I have has an opportunity to review

this waiver and ask any question concerning its meaning or intent.

In the event my child is injured or becomes ill during a Georgia Baptist Convention/Youth Ministries Office event or

activity, I hereby grant permission for (1) the Event Administrator, (2) any employee or representative, or (3) the person(s) on the

medical team to obtain and/or provide for my child necessary medical attention and treatment, including but not limited to

emergency medical care provided by a hospital, medical clinic, or other emergency health care provider.

I verify that I have read this entire document, have had reasonable opportunity to ask questions concerning its application,

understand its contents, and acknowledge that the various information provided throughout this document is accurate and

complete. I further acknowledge and verify that I have full legal authority to execute this document and that there are no

requirements, conditions, or obligations, legal or otherwise, which would require the consent or assent of any other person or

entity. Signed this the _____ day of _________________________, 20____.

_________________________________________

Signature of Parent or Guardian

Notary Public

I, the undersigned officer duly qualified and authorized to administer oaths, do hereby state and affirm that

_________________________________________ personally known by me, appeared before me and in my presence executed the

above and foregoing Medical Waiver together with its Medical Power of Attorney and Release. Witness my hand and seal this

_____ day of ________________________, 20_____.

_________________________________________________

Notary

NOTARY SEAL

My commission expires ______________________________

Medical Waiver/release Form Page 2