Little Country Church Release Waiver Of Liability And Indemnity

Little Country Church Release, Waiver of Liability, and Indemnity Agreement

Student Name: _____________________________________________________ Sex: M / F

Birth date: _____/_____ /_______ Students Cell: _________________________ Graduation Year: __________

E-Mail:________________________________________ Address: ________________________________________City:_____________________________ Zip Code: __________ School: __________________

Parent(s)/Custodial Adult(s):

Name: ________________________________________ Relationship: _____________ Work Phone: _____________________ Cell Phone: ____________________E-Mail: _______________________________

Name: ________________________________________ Relationship: _____________ Work Phone: _____________________ Cell Phone: ____________________E-Mail: _______________________________

Emergency contacts WHEN THE PARENT(S) CANNOT BE REACHED:

Name: _______________________________ Relationship:_____________ Phone: __________________ Name: _______________________________ Relationship:_____________ Phone: _________________

Authorization to Obtain Urgent or Emergency Medical Care / Medical Record and Release:

The undersigned do hereby authorize, Little Country Church in Redding

, staff, and volunteers

, as agents for the undersigned to consent to any x-ray examination, anesthetic, medical, dental or

surgical diagnosis or treatment and hospital care for the above minor which is deemed advisable by and to be rendered under the general or special supervision of any physician and surgeon,

licensed under the provision of the MEDICINE PRACTICE ACT or of any dentist licensed under the DENTAL PRACTICE ACT, at a hospital or elsewhere. In the absence of parent or guardian, the

above-mentioned agent is authorized to make decisions concerning the positive health and welfare of this minor. First aid and non-prescription medication will be administered at the adult leader's

discretion, with the following exceptions: ________________________________________________________________________

Will Medications be needed for your student? Yes / No

Please List with Instructions: _________________________________________________________________________________________________

Allergies / Special Health Concerns: _______________________________________________________________________________________________________________________________________________

Date of last Tetanus shot: ____/____/_____ Medications your child CANNOT Take: _____________________ Physician Name: ___________________________________ Phone: _______________________

Medical Insurance Company: _____________________ Medical Insurance Phone Number: ___________________Policy/Group Number: _____________________ Participant Number: ________________

Name, Address & Phone Number of Employer where coverage is located: ______________________________________________________________________________________________________________

Permission to Participate; Release, Waiver of Liability, and Indemnity Agreement

I/we give permission for ________________________________ to (name of child/youth) participate in the activities of Little Country Church, both on the church premises and elsewhere. In thought

of the opportunity of my/our child/youth to participate in the activities of Little Country Church, I/we release Little Country Church, its officers, agents, employees, staff, and volunteers from any and

all liability of any kind whatsoever for any loss or injury to my/our child/youth arising from my/our child/youth's participation in the activities of Little Country Church; and I/we agree to indemnify and

hold forever harmless the Little Country Church, its officers, agents, employees, staff, and volunteers from any and all liability of any kind whatsoever for loss or injury to my/our child/youth arising

from activities on or off the premises of Little Country Church or resulting from traveling to or from the activities of Little Country Church, including loss or injury resulting from negligence or gross

negligence. I/we understand and agree that this permission and agreement shall remain in effect until revoked in writing by me/us, and I/we understand and agree that it is my/our responsibility to

update our child/youth's medical and insurance information as changes occur.

Photo Permission

I/we understand that my child may be photographed while participating in the activities of Little Country Church. I/we give permission for a recognizable image of my child to be posted on the

Little Country Church websites, bulletin boards, LCC Facebook groups, or used in promotional materials. I understand that the Little Country Church will not include my child’s last name or any

identifying information. I understand that a non-recognizable image, such as a group picture, may be posted as well.

Disciplinary Agreement

I/ we understand that, while the above-named child participates in any regularly sponsored activities, or special events he or she is responsible to abide by the rules set forth by the sponsoring

ministry, its leader and supervisory personnel. Any serious infraction of rules and/or conduct by the child can result in dismissal from the program. In the event your child is dismissed from the

program, I/we the undersigned, agree to assume the cost of returning the child to his or her home. We also agree to forfeit any possible refund. (We understand that such action would only be taken

under extreme circumstances and only after direct consultation with the child’s pastor and parent or guardians)

I/ we the undersigned am in agreement with and consent to each the above items; Authorization to Obtain Urgent or Emergency Medical Care / Medical Record and Release, Permission

to Participate; Release, Waiver of Liability, and Indemnity Agreement, Photo Permission and Disciplinary Agreement. This authorization will remain effective while the above minor is in the

care of Little Country Church in Redding from the dates October 1, 2011 through and including December 31, 2012 unless revoked in writing by the undersigned, and delivered to the aforesaid

agent.

Signature of Parent/Guardian: ______________________________________ Date: ____/____/_____ Signature of Parent/Guardian: __________________________________________ Date: ____/____/_____