Fill and Sign the Activity Release Form

Youth Church Activity Waiver by Parent or Legal Guardian and Release to give Medical Information of Child if Child requires Immediate or Emergency Medical Care The undersigned Parent or Legal Guardian, hereinafter called Guardian , hereby gives permission to       , a nonprofit Church Corporation organized (Name of Church) and existing under the laws of       , with its principal office located (Name of State) at       , referred to herein Church, for my Child (Street Address, City, County, State, Zip Code)       , hereinafter referred to as the Child, to take part in the (Insert Child’s Name) following activity       . (Describe Activity) Should my Child require immediate or emergency medical care while engaged in the aforesaid activity sponsored by the Church, in my absence, I hereby grant the Church authority to release my Child for medical treatment to such medical personnel as the Church determines appropriate under the circumstances. In consideration for the privilege of allowing my Child to participate in the activity described above, I release and hold harmless the Church, its officers and agents, from any liability to or responsibility for bodily injury, damage or illness to the Child while participating in the aforesaid activity. Further, I agree to indemnify and hold harmless the Church, its officers and agents with respect to any claim asserted by or on behalf of my Child as a result of bodily injury, illness, or damage. PLEASE READ THIS DOCUMENT CAREFULLY. IT CONTAINS A RELEASE OF LIAIBLITY AND A PROMISE TO INDEMNIFY. Guardian’s Telephone number(s) are: Home:       Work:       . Emergency Information:  In an Emergency Contact:        Primary Phone #:        Secondary Phone #:        Other Phone #:       Insurance Company:       Known allergies of Child:             Youth Church Activity Waiver by Parent or Legal Guardian Page 1 of 2 Special medical history of Minor:                   Witness our signatures this the       day of       , 20       .             (Name of (Child) (Name of Parent or Guardian) By: ___________________________________ (Signature of Child) (Signature of Parent or Guardian)             (Printed Name Child) (Printed Name of Parent or Guardian) Youth Church Activity Waiver by Parent or Legal Guardian Page 2 of 2