PERMISSION AND RELEASE OF LIABILITY
PERMISSION AND RELEASE OF LIABILITY WHILE PARTICIPATING IN CHILDREN/YOUTH PROGRAMMING WITH ST. MARK'S UNITED METHODIST CHURCH OF BLOOMINGTON, INDIANA

In return for being accepted by St. Mark’s United Methodist Church for participation in normal and/or ongoing children/youth activities during church program year, January 1, 2017 through January 1, 2018, I/We do hereby for and on behalf of my/our selves and on behalf of any child/youth participant(s) agree to accept and assume the risk of the above referenced activity fully understanding that there are risks in any trip or activity and being aware of those risks do
hereby release, forever discharge, and agree to hold harmless St. Mark’s United Methodist Church, its agents, employees, volunteers, ministers, staff, and congregation from and against any and all liability, claims or demand 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/or the child/participant while participating in the above-described trip or activity. I/We specifically give my/our child/youth permission to participate in the above activity and I have had an ample opportunity to ask questions and obtain information regarding the trip or activity.

I/We specifically assume all risk of personal injury, sickness, death, damage, and expenses as a result of participation by my/ourselves or my/our minor children/youth in any recreation or work activities involved with the above-referenced activity. I/We further authorize St. Mark’s United Methodist Church to furnish any necessary transportation, including activities including field trips in and around the Bloomington, Indiana area and that my/our child will be transported in vehicles driven by church staff and volunteers, not younger than 18 years of age.

Additionally, I/We delegate my/our authority to consent to the healthcare of my minor child to an authorized representative of St. Mark’s United Methodist Church and authorize such individual to make all healthcare decisions, consents and authorizations for the healthcare of my minor child. This delegation is given pursuant to Indiana Code § 16-36-1-6.
I/We specifically agree to assume the responsibility of all medical bills that may be incurred.

Email address
Name of Child/Youth Participant
Your answer
Parent(s) Name and Telephone Number
Your answer
Is child/youth covered by hospital insurance?
If YES, provide Insurance Company Name.
Your answer
Physician's Name and Phone Number
Your answer
Emergency Contact Name and Phone Number
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Enter Parent Name (to represent signature) and Date
Your answer
Enter Parent Name (to represent signature) and Date
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Enter Legal Guardian Name (to represent signature) and Date
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Video/Photo Release: Do you give permission for your child/youth to be photographed or videotaped during church activities?
A copy of your responses will be emailed to the address you provided.
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