Liability And Release Form For Library And City Park printable pdf download

Liability and Release Form

For Library and City Park

In consideration for being allowed by First Place Academy to go to the City Park in Trenton Fl and the County Library on

occasion when the school decides to go during the 2015-2016 school year. We (I), being 21 years of age or older, do for

ourselves (myself) (and for and on behalf of my child-participant if said child is not 21 years of age or older) do herby

release, forever discharge and agree to hold harmless First Baptist Church of Trenton/First Place Academy, the pastors,

the staff and the directors thereof from any and all liability, claims or demands for personal injury, sickness or death, as

well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the child-

participant that occur while said child is participating in any and all activities, work projects or trips.

Furthermore, we (I) [and on behalf of our (my) child-participant if under the age of 21 years] here-by assume all

risk of personal injury, sickness, death, damage and expense as a result of participation in recreation and work activities

involved therein.

The undersigned further hereby agree to hold harmless and indemnify said church/academy, pastors, its

directors, employees and agents, for any liability sustained by said church as the result of the negligent, willful or

intentional acts of said participant, including expenses incurred attendant thereto.

(If the participant has not attained the age of 21 years)

We (I) are the parent(s) or legal guardian(s) of this participant, and hereby grant our (my) permission to take said

participant to a doctor or hospital and hereby authorize medical treatment, including but not limitation to emergency

surgery or medical treatment, and assume the responsibility of all medical bills, if any.

Further, should it be necessary for the participant to return home due to medical reasons, disciplinary action or

otherwise, we (I) hereby assume all transportation costs. I also grant my permission for photos to be taken of my child

and used by First Baptist or First Place to publish for promotion of events and church/academy activities.

(Only participant sign if 21 years of age or older. If under 21, both parents must sign unless parents are separated or divorced in which case the

custodial parent must sign.)

_________________________________________

________________________________________

(Type or print name of participant)

Father

Date

_________________________________________

(Parent(s) telephone #)

________________________________________

Mother

Date

Hospital insurance [ ] Yes [ ] No

________________________________________

Insurance Company

Legal Guardian

Date

__________________________________________

Policy Number______________________________

Emergency Phone #’s (not home phone)

Physician__________________________________

Physician’s phone#__________________________

_______________________________________

Please List any allergies or medication on the reverse side of this sheet.

Liability And Release Form For Library And City Park

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