MEDICAL AND LIABILITY RELEASE

The Student Ministry of Pleasant Dale Church

4505 W 300 N  Decatur, IN 46733  (260) 565-3797

 

This release applies to: all activities associated with Pleasant Dale Church of the Brethren.
Dates that this release applies to: June 1, 2009 to December 31, 2010

 

I give permission for ________________________________________, to participate in all activities associated with the ministry of Pleasant Dale Church of the Brethren, Decatur, IN.  I understand that every activity sponsored by this church is carefully planned and supervised by mature adults.  However, even with the best of planning and precaution, I know that unforeseen events can occur.  Therefore, I accept full responsibility for this student's participation in Pleasant Dale Church of the Brethren activities, including transportation to and from any location in connection with church sponsored activities.  I also agree that I will not hold Pleasant Dale Church of the Brethren or its employees or volunteer workers or members liable for damages, losses, illnesses, or injuries to the individual named on this form.  I will assume full responsibility for any medical costs incurred in the event of an accident or other incident requiring medical treatment. I release Pleasant Dale Church of the Brethren from any liability. In the event of an emergency in which the student is in need of immediate hospitalization, medical attention or surgery, and after reasonable efforts have been made to contact me and the other emergency contacts listed on the Student Medical Information Form and we cannot be located for the purpose of consenting thereto, consent for the emergency attention may be given by the youth pastor or any volunteer youth worker. It is understood that the subject of this release will obey all regulations and follow instructions of the leaders and representatives of the ministry of Pleasant Dale Church of the Brethren.  I agree to pay any expenses incurred as a result of disciplinary issues, including the cost of transporting the student home if deemed necessary. 

 

I understand that this form and my signature are for both medical and liability release.

Parent/Legal Guardian Signature __________________________________Date:_______________
 

Student Signature (if 18 or over): __________________________________Date:_________________

 

Print Signer's Name: _________________________________________________


Local Person to contact in the event of an emergency:

Name: ________________________________________ Phone: _____________________________

 

Please indicate below any changes to medical or contact information listed previously in the

Student Medical Information Form (if you would like a copy of your Student Medical Information Form, please contact the church office).