Medical Release Form printable pdf download

MEDICAL RELEASE FORM

AND INDEMNITY AGREEMENT

Cowboy Fellowship of Atascosa County

I understand that my child ______________________________________________, hereinafter Minor, will be allowed to take

in-town and out-of-town trips with Cowboy Fellowship of Atascosa County, Texas Inc. (hereinafter Cowboy Fellowship). We

agree that the Youth Sponsors, Adult leaders and Cowboy Fellowship shall not be held responsible for any accident or

misfortune, which might occur in connection with these activities. You may also be assured that he/she is being permitted to

make these trips with our consent.

We further give full authority to the youth leader(s) to discipline Minor as the youth leader(s) deem necessary. If Minor’s

behavior is such that it endangers the happiness or safety of the entire group, then the youth leader(s) has our permission to

send Minor home after notifying us of his/her intention to do so. We further promise to pay the cost of Minor’s return trip

home if this action becomes necessary. In consideration of the foregoing, as well as the supervision provided on our behalf and

on the behalf of Minor, we hereby hold the youth leader(s) and/or Cowboy Fellowship harmless for the results of any decisions

he/she in his/her discretion shall make.

Minor has assured us that he/she shall conduct himself/herself is such a way that reflects Godly, Christian Conduct upon this

group he/she represents. Minor understands and has signed “The Promise” described below.

THE PROMISE:

I hereby promise to obey any rules and regulations laid down by the group leader(s). I realize that

such rules are necessary for the safety and happiness of the entire group. I will cooperate with the

youth leader(s) and other members of the group. I know the serious breaking of these rules may

mean my return home.

___________________________________________________(1/1/2015-12/31/2015)

(Signature of Minor)

As is authorized in Section 32.001 of the Family Code of the State of Texas entitled “Consent by Non-Parent”, in the event on

an accident or illness concerning Minor, Cowboy Fellowship acting by and through its adult representatives will use its best

effort to contact the parent(s) or legal guardian of Minor as soon as is reasonably possible. In the event the parent(s) or legal

guardian is not available, a minister of Cowboy Fellowship, a staff member of Cowboy Fellowship or other adult volunteer

sponsor, as adults who have the actual care, control, and possession of Minor are authorized by this written document to secure

and consent to such medical, dental, psychological, and/or surgical treatment for Minor as they in their sole discretion shall

deem necessary for the treatment of the accident or illness.

I, the undersigned parent or legal guardian, assume full responsibility for all medical bills, doctor bills, and/or hospital bills or

otherwise incurred by Minor. Further I agree to indemnify and reimburse Cowboy Fellowship, and/or any other agents,

employees, sponsors, volunteers, or otherwise of Cowboy Fellowship who shall incur such expenses in the treatment of the

accident or illness of Minor the full amount which shall be expended.

I certify that the information I have given is correct, and that both parents/legal guardians (if possible) have read and

I also agree that this agreement is good for the duration of one full year from

understand this agreement.

1/1/2015 through 12/31/2015.

Photo Consent

Upon signing this agreement, the parent/legal guardian (please circle) DOES

DOES NOT

give permission to

allow any recreational photos the student may be in to be placed on the church website/Facebook page/newsletters/ etc. Not

specifying will be taken as allowing the photos to be used.

PARENT SIGNATURE_____________________________________________ DATE_________________________________

PLEASE TURN OVER AND FILL OUT MEDICAL INFORMATION

What is the student’s shirt size?

AXL AXXL

(YOUTH events DO NOT go smaller than a Youth Large)

Medical Release Form

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