Youth Group Medical Release Form (Page 2 of 2) in pdf

St. Georges Youth Group

Liability Release Form 2011-2012

DEFINITION: “St. George’s” means the Clergy, Officers, Vestry, employees, and youth ministry volunteers of the Church of St

George’s..

The undersigned parent(s) or guardian(s) and the undersigned participant hereby represent that the participant is the child or ward of

the parent(s) or guardian(s). The parent(s) or guardian(s) and the participant understand that this program may involve travel in mixed

groups and riding in private vehicles utilizing available local accommodations for travel, meals, and lodging. It is understood that St.

George’s will employ only the usual and locally acceptable standards of instruction, travel, meals, lodging, and medical services.

Adult members of the Youth Group staff will determine the day-to-day operations of the program as they deem appropriate. St.

Georges’s has a history of successful operations, but St. George’s is not an insurer of the health, well-being, safety, or morals of any

participant and cannot guarantee every participant will achieve the education or obtain the enjoyment anticipated from the program.

It is understood that the program may be hindered disrupted, or rendered impossible by: changes, irregularities, or failure in

transportation services, lodging accommodation, and food services; strikes, mischief, terrorist acts, or war; lack of cooperation or

sickness of one or several of the participants; governmental restrictions and regulations; and weather or other acts of God. The

parent(s) or guardian(s) and participant accept these hazards as those which may accompany these types of activities.

Parent(s) or guardian(s) and participant represent to St. George’s that the participant is in good physical and emotional health and is a

person who is likely to give the required cooperation toward the success of the program and that the participant is not likely to

interfere unreasonably with the rights of other participants or those in charge of the program. In the even that St. George’s should

determine that the physical or emotional health of a participant is such that further participation by him/her would endanger his/her

health or welfare or the health or welfare of other participants or if St. George’s should determine that a participant behaves in a

manner detrimental to the best interest of the program or other participants, St. George’s may expel such a participant from the

program. The parent(s) or guardian(s) and participant agree to pay the costs of returning the participant to his/her home and hereby

release St. George’s from any liability arising out of such expulsion and agree that no refund of the program fee will be allowed.

CANCELLATIONS: Cancellation by a participant or his/her family will result in the forfeiture of any money actually spent or

committed on behalf of the participant up to the date of cancellation.

CHANGES: This program has been designed long before departure. St. George’s reserves the right to amend any program for

operational reasons and/or in the best interest of the participants’ safety and convenience. St. Georges’s reserves the right to cancel the

program prior to departure. In the event St. George’s cancels, St. George’s shall refund all monies received for the canceled

program. In any case, St. George’s shall have no other liability to the participants.

RIDING IN PRIVATE VEHICLES: It is understood by the parent(s) or guardian(s) and participant that transportation for this

program will be primarily in private vehicles driven by the youth ministry volunteers and staff. It is understood that every effort will

be made to have more than one adult in each vehicle; however, if the youth staff deems it appropriate, exceptions may be made to this

policy for this program. The parent(s) or guardian(s) hereby give permission for the participant to ride in private vehicles with only

one adult and agree to release and hold harmless St. George’s from any claims or demands, for injuries or damages arising out of the

enacting of the above-stated policy and its exceptions.

MEDICAL RELEASE: In case of emergency, the parent(s) or guardian(s) understand that every effort will be made to contact them.

In the event that they cannot be reached, they hereby give permission to the physician(s) or dentist(s) selected by the St. George’s

staff to hospitalize and secure proper treatment, including tests, x-rays, anesthesia, and/or surgery, for the participant.

RELEASE: The parent(s) or guardian(s) and participant hereby release St. George’s from any and all claims or demands, for injuries

or damages arising out of the acts or omissions of the independent contractors employed by St. George’s, such as theme parks, ski

resorts, restaurants, places of lodging, doctors, and dentists; the acts or omissions of other participants or strangers; the acts or

omissions of St. George’s performed or omitted in good faith and in a manner reasonably believed by them to be within the scope of

authority granted to them by this agreement and in the best interest of the majority of the participants in the program, unless they are

guilt y of gross negligence or willful or wanton misconduct.

PHOTOGRAPHS: Any photograph or audio or video recording of the participant or comments or statements made by the participant

may be used in future materials by St. George’s and/or posted on the St. George’s Church website.

CONSENT: The parent(s) or guardian(s) hereby give their permission and consent for the participant to participate in the program.

The undersigned agree that upon admission of the participant into the program, they will be bound by the terms of this Release and

Agreement. The undersigned acknowledge that they have read and understand the terms of the Release and Agreement. This Release

and Agreement supersedes and nullifies any previous agreement, implied or expressed, made between St. George’s and the

undersigned for this program.

_____________________________________ _____________________________________

Mother or legal Guardian

Date

Father or legal Guardian

Youth Group Medical Release Form Page 2

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