The Minor Release Form - Fryeburg New Church Assembly printable pdf download

Release Form for Minors Unaccompanied by Parent

RELEASE, WAIVER AND INDEMNITY AGREEMENT FOR MINORS UNACCOMPANIED BY A PARENT

If the registrant is under 18 and will not be accompanied by his or her parents, his or her parent must complete and sign

this form and designate a adult who is present at Fryeburg New Church Assembly (hereinafter FNCA) the authority to act

as the minor’s guardian, administer first aid or take child to the hospital if needed.

The undersigned parent and guardian of ______________________ (minor’s name) hereby voluntarily and

absolutely releases, discharges, waives, and relinquishes any and all loss, damages, actions, or cause of action for per-

sonal injury, property damage, or wrongful death occurring to _______________________(minor’s name) as a result

of _____________________ (minor’s name) using FNCA’S facilities or equipment , or engaging in any FNCA activities,

some of which involve dangers and risk of bodily injury.

The undersigned parent and guardian of _____________________(minor’s name) agrees that in the event of any

personal injury, property damage, or wrongful death involving said minor, the undersigned parent and guardian will

indemnify and hold harmless FNCA and its officers, agents, and employees from any and all claims or cause of action

with regard to _______________________(minor’s name).

Under no circumstances will the undersigned parent and guardian of _______________________(minor’s name)

present any claim against FNCA and said persons for personal injuries, property damage, wrongful death, or otherwise,

caused by any act of negligence caused by FNCA and said persons.

The undersigned parent and guardian represent that he/she has read this Release, assumes all risks associated with such

dangers and risks, and understands the terms and legal consequences of the signing of this Release. The undersigned

and

parent

guardian intend his or her signature to be a complete and unconditional release of all liability to the greatest

extent allowed by law.

Name of Minor________________________________________________________ Age______________

Name & Signature of Parent(s)_____________________________________________________________

Name & Signature of Guardian_____________________________________________________________

Medical Insurance Information, Subscriber’s Name & Policy # _____________________________________

Date Signed _______________

Medical Information

Does your minor have any chronic or acute medical problems?

Yes: _________

No:_________

If Yes, please explain: ______________________________________________________________________________

List any allergies (food, medicine, pollen etc.): ___________________________________________________________

_________________________________________________________________________

List any current medications: ________________________________________________________________________

________________________________________________________________________

List any other conditions we should be aware of: _________________________________________________________

________________________________________________________________________

The Minor Release Form - Fryeburg New Church Assembly