CITY CENTER FOURSQUARE CHURCH
LIABILITY RELEASE FORM
YOUTH MINISTRY ACTIVITIES
2003 - 2004
I give my permission for __________________ to be involved in off-site activities with City Center Foursquare Church Youth Ministry. I do hereby release, forever discharge and agree to hold harmless, City Center Foursquare Church and the directors thereof from any and all liability, claims or demands for personal injury, sickness or death, as well as property damage and expense of any nature whatsoever which may be incurred by the undersigned and the participant that occur while said person is participating in the activities of City Center Foursquare Church. The undersigned further hereby agrees to hold harmless and indemnify said church, its directors, employees and agents of transportation for any liability sustained by said acts of said participant, including expenses incurred attendant thereto.
Signed this ____ day of ___________ 20___
The undersigned further consents to the administration of first-aid/or doctor's care, or any other form of medical treatment, necessitated by illness or injury that may require the same. In the event of the necessity of such care or treatment as heretofore described, the undersigned agrees to hold harmless and indemnify said church, its directors, employees and agents from any acts of malfeasance, and/or failure to act on the part of those chosen to administer medical care on behalf of the participant. I have listed below all known allergies, medical conditions and medications of my child.
Parent's Signature _________________________
Address __________________________
Phone _______________ 2nd contact # (work, cell, etc.) __________________
Name of Insurance Carrier: _______________________________
Subscriber's Name: __________________ Insurance ID#: _____________
List all known allergies/medical conditions: ____________________________________________________________________________
List all known/necessary medications: ____________________________________________________________________________
Additional Comments/Instructions: ____________________________________________________________________________
Please list below the name of a friend or relative to call in case a parent cannot be reached in an emergency:
Name ______________________________ Phone _______________
*Print a blank form and fill in after printing. Then return to City Center Foursquare's office.
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