2023-2024 Child/Youth Medical Form and Liability Release
Medical Form and Liability Release for child/youth participation in events where these are required through Lakewood Congregational Church (United Church of Christ), 1375 West Clifton Blvd., Lakewood, OH 44107. This form must completed annually. This form is for LCC events June 2023-August 2024.
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Child's first and last name  *
What first name does your child prefer to go by? *
Child's Pronouns *
Child's Date of Birth *
Parent/Guardian  name(s) and contact information. (List all parents/guardians) *
If parents/guardians cannot be reached in case of emergency, please contact: (name, phone number, relationship) *
Hospital/Clinic Preference *
Please list all allergies, reaction, and treatment. If no allergies, list "n/a". *
Additional comments including, but not limited to, medications, behavioral concerns, special needs, accommodations, etc.
Is your child/youth bringing any medications (including over the counter and prescription) to the event? (All medications must be reported in the previous question.) *

Participant Release and Indemnification For A Minor
I/We, the undersigned parent(s)/guardian(s) of the child/youth listed on this form, a minor under the age of eighteen (18), do hereby grant permission for Participant to participate in the activities and ministries of Lakewood Congregational Church, United Church of Christ (“LCC”), and in consideration thereof, hereby freely and voluntarily execute this Release under the following conditions:
1.       GENERAL RELEASE: I/We, on behalf of myself/ourselves and Participant, release, protect, indemnify, forever discharge, and hold harmless LCC and its directors, officers, employees, volunteers, agents, successors and assigns from any and all liability, claims, demands, actions, costs, expenses, damages, defenses, or causes or action of whatever nature, kind, or description, known or unknown, either in law or in equity, now existing or hereafter acquired, from Participant’s activities with LCC. This release includes, but is not limited to, all losses and damage of any kind to property or personal injury (including death), based upon any activity, accident, incident, or occurrence arising out of, incidental to, or in any way resulting from my participation in LCC activities or ministries, even if caused by the strict liability or negligence (whether sale, joint, or concurrent) or LCC and whether asserted by me or any person claiming by, through, or under me.
2.       MEDICAL RELEASE: I understand and acknowledge that LCC does not assume any responsibility for or obligation to provide financial assistance or other assistance in the event of injury or illness. I understand and acknowledge that LCC does not carry or maintain health, medical, or disability insurance coverage for any participant. I do hereby authorize adult volunteers of LCC as agent(s) for the undersigned, to consent to any medical or surgical care deemed advisable by an accredited physician or surgeon in an approved emergency clinic or hospital. I further release from any liability LCC, any of its ministers, staff, or leaders in the event of an accident en route, during and returning from LCC events. This agreement does not apply to claims for intentional misconduct or gross negligence.
3.       MEDIA RELEASE: I further irrevocably grant to LCC, its assigns and successors, my consent and full right to: use Participant’s name, photograph, likeness, image, voice and biography in any and all media, publications, advertising, and publicity, in connection with Participant’s participation hereunder.
4.       STANDARDS OF CONDUCT: I/We agree that Participant will comply with all laws and ordinances and with LCC’s rules, standards, and instructions for behavior for LCC activities and ministries and agree that LCC has the right to enforce standards of conduct, in its sole judgment.
5.       GENERAL PROVISIONS: I expressly agree that this Release is intended to be as broad and inclusive as permitted by the laws of the State of Ohio, and that this Release shall be governed by and interpreted in accordance with the laws of the State of Ohio. I agree that in the event that any clause or provision of this Release shall be held to be invalid by any court of competent jurisdiction, the invalidity of such clause or provision shall not otherwise affect the remaining provisions of this Release, which shall continue to be enforceable. The headings contained in this Agreement are for reference purposes only and shall not affect in any way the meaning or interpretation hereof.
Parent/Guardian Signature: by typing your name below, you agree that all information in this form is correct and that you agree to the Participant Release and Indemnification For A Minor. *
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