Release Of Liability And Statement Of Responsibility Form printable pdf download

Release of Liability and Statement of Responsibility Form

In consideration for being allowed by Bethel Temple Assembly of God and the directors and other

members of the Explorers Coop to participate in homeschool classes, Science Olympiad preparation, and

associated field trips I do hereby agree to the following:

1. To release, forever discharge and agree to hold harmless Bethel Temple Assembly of God , the

members and guests thereof, the Explorers Coop, its members and guests 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 participant that

occur while said person is participating in the above-described trip or activity including recreation and

work activities. The undersigned further hereby agrees to hold harmless and indemnify said church and

Coop, its directors, members, employees and agents for any liability sustained by said participant,

including expenses incurred attendant thereto.

2. To reimburse Bethel Temple Assembly of God for any and all damages caused to the facilities and/or

the equipment therein inflicted either by accident or malice.

3. To the administration of first-aid and/or doctor’s care, or any other form of medical treatment

necessitated by illness or injury that may require the same. In the event of the necessity of such care or

treatment as heretofore described, the undersigned agrees to hold harmless and indemnify Bethel Temple

Assembly of God and Explorers Coop, its directors, members, employees and agents from any acts of

malfeasance, and/or failure to act on the part of those chosen to administer medical care on behalf of the

participant.

4. To abide by and follow the rules found in the Explorers Coop handbook.

Participant / Child’s Name ________________________________________________________

Signature of Parent / Legal Guardian _______________________________________________

Signed this day _________of_______, 20 ______

Participant’s Insurance Company __________________________________________________

Policy Number __________________________________________________________________

Telephone: Home ___________________________ Cellular ______________________________

Accepted by Director / Leadership Team ________________________________________________________

Release Of Liability And Statement Of Responsibility Form