Medical Release

I (we), the undersigned parent(s)/legal guardian(s) of a minor, do hereby authorize New Life Church, Inc. of Yorkville, IL, as agents for the undersigned, authorize an adult, in whose care the minor has been entrusted, to consent to any X-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment, and hospital care, to be rendered to the minor under the general or special supervision and on the advice of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital.
The undersigned shall be liable and agree(s) to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child pursuant to this authorization.
Should it be necessary for our (my) child to return home due to medical reasons, disciplinary action or otherwise, the undersigned shall assume all transportation costs.
The undersigned does also give permission for our (my) child to ride in any vehicle designated by the adult in whose care the minor has been entrusted while attending and participating in the activities sponsored by New Life Church, Inc of Yorkville, IL.

I will assume the financial responsibility for any property or equipment that is damaged as a result of my child’s carelessness or negligence.

NEW LIFE CHURCH ● 3205 Cannonball Trail ● Yorkville ● 630.553.0200 nlcyorkville.org

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