Liability Release Form
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1Liability Release Form
In consideration for being accepted by Central Church of God for participation in any extra-curricular activity
(i.e., Fun Nights, trips, etc.) for the year 2014, we/(I), being 18 years of age or older, do for ourselves (myself)
[and for and on behalf of my child-participant if said child is not 18 years of age or older] do hereby release,
forever discharge and agree to hold harmless Central Church of God 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 the above described trip or activities involved therein.
Furthermore, we/(I) [and on behalf of our (my) child-participant if under the age of 18 years] hereby 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, 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 18 years:
We/(I) are the parent(s) or legal guardian(s) of this participant, and hereby grant our/(my) permission for him/her
to participate fully in said trip, and hereby give our/(my) permission to take said participant to a doctor or hospital
and hereby authorize medical treatment, including but not limited 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.
Finally, we/(I) grant our/(my) permission for Central Church to use any or all photographs of our/(my) child(ren)
on the Central Church of God/Kids Central webpage. We/(I) understand that the staff of Kids Central will make
every effort to remove any identifying information from the picture before posting it on the site.
_______________________________
Male
Female
Birth Date: _______/_______/_______
Type or Print Name of Participant #1
_______________________________
Male
Female
Birth Date: _______/_______/_______
Type or Print Name of Participant #2
Only participant need sign if 18 years of age or older.
(
)
If under 18, parent(s) must sign.
Parent(s) / Guardian(s) Home phone #
(
)
Parent(s) / Guardian(s) Work phone #
Sign: Mother
Date
(
)
Parent(s) / Guardian(s) Cell/Pager #
Sign: Father
Date
Insurance Company (insurance required)
Sign: Legal Guardian
Date
___________________________________________
Sign: Participant
Date
Policy #
Family Physician
Emergency Contact: Name & Phone #
(
)
Physician’s Telephone #
Parent(s) Birth Date: _______/_______/_______
Parent(s) / Guardian(s) Home Address: __________________________________________________________________________
Parent(s) / Guardian(s) Work Address:___________________________________________________________________________
*Please attach a photocopy of Hospital Insurance Card & Prescription Card
(front and back of each card)
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