Annual Liability Release Form
Release of All Claims
In consideration for being accepted by The Church of Genesis of New Castle, PA for participation in activities sponsored or attended on or between December 1, 2008 and January 1, 2010, we do hereby release, forever discharge and agree to hold harmless The Church of Genesis of New Castle, PA 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 trips or activities noted above.
Furthermore, we hereby assume all risk of personal injury, sickness, death, damage and expenses as a result of participation in recreation and work activities involved therein. Further, authorization and permission is hereby given to said church to furnish any necessary transportation, food and lodging for this participant.
The undersigned further hereby agree to hold harmless and indemnify said church, its directors, employees and agents, for any liability sustained by such church as the result of negligent, willful, or intentional acts of said participant, including expenses incurred attendant thereto.
We are the parents or legal guardians of this participant, and hereby grant our permission for him/her to participate fully in said trip, and hereby give our permission to take said participant to a doctor or hospital and hereby authorize medical treatment, including but not in limitation 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 reason, disciplinary action or otherwise, we hereby assume all transportation costs.
______________________________________________________ Hospital Insurance (please circle one)
Participant's Name (please print) YES NO
Age____________ ___________________________________________________
Insurance Company
_______________________________________________________
Street Address, Apt. No. ___________________________________________________
Policy Number
_______________________________________________________
City, State, Zip Code ___________________________________________________
Physician's Name
(___________)___________________________________________
Phone Number (___________)______________________________________
Phone Number
__________________________________________________
Allergies or Health Conditions: Emergency Contact #1
______________________________________________________ (____________)_____________________________________
Phone Number
______________________________________________________
__________________________________________________
______________________________________________________ Emergency Contact #2
______________________________________________________ (____________)____________________________________
Phone Number
Father's
Signature_____________________________________________Date___________________________
Mother's
Signature_____________________________________________Date___________________________
Legal Guardian's
Signature_____________________________________________Date___________________________
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