Consent to Transport Waiver and Release Form
Completed by the Person to be Transported
Name *
Your answer
Address *
Your answer
City *
Your answer
Date of Birth *
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Cell Phone *
Your answer
Emergency Contact Name: *
Your answer
Relationship: *
Your answer
Emergency contact phone# *
Your answer
Transportation Waiver and Release
I, the undersigned, give my consent for the person identified above to be transported by New Life Church Ypsilanti and will assume all liability for my participation in this activity/event and any injury that may result during the transport or at the event/activity.
Further, by signing below:
1. I will not hold the Church, its officers, agents, employees, assigns or anyone acting on its behalf, responsible or liable for injury occurring to the named person in the course of such activities or such travel.
2. I hereby accept financial responsibility for personal items lost by the person identified
herein.
3. I authorize the Church to transport and to obtain, through a physician of its own choice, any emergency medical care that may become reasonably necessary for the person in the course of such activities/events or such travel, and agree to accept the cost of the transportation and/or treatment by medical personnel or facility.
4. I accept full responsibility and hereby grant permission for me and/or my minor
child to travel with the Church.
This Waiver and Release will be valid for all transportation occurring as of and after the below
Date. August 31, 2019 through August 31, 2020.
Do you agree to the terms and conditions? *
Today's Date *
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