| Event Participation & Liability Release Form |
| Name____________________________ Phone________________________ Address________________________________________________________ City_____________________________ Zip____________________ In case of emergency, notify:________________________________________ Relationship___________________________________ Phone Number_________________________________ Doctor's Name_________________________________ Phone Number_________________________________ Allergies Insect Bites________________ Drugs______________________ Food Allergies______________ Other______________________ Any activity restrictions?___________________________________________ Can your child swim? Yes_____ No_____ The church's insurance is only secondary insurance. If you have medical insurance, your carrier will be billed for medical charges in the case of illness or injury while your son or daughter is on a church-related activity. Do you have health insurance? Yes_____ No_____ If "Yes" Name of Company:________________________________ Policy Number:___________________________________ Address:_________________________________________ _________________________________________ LIABILITY RELEASE Every activity sponsored by Rye Hill Baptist Church is carefully planned and adequately supervised by mature adults. However, even with the best planning and precautions, unforseen events can occur. By signing this form, the parent or guardian agrees to assume and accept all risks and hazards inherent in church-related social activities. They also agree not to hold Rye Hill Baptist Church, it's employees or volunteer assistants liable for damages, losses, or injuries to the person above mentioned. The parent or guardians understand that they are signing for the minor listed on this form and the signature is for both a medical and liability release. "In the event that I cannot be reached in an emergency during the time my child is in the care of Rye Hill Baptist Church, I hereby give my permission to the physician or dentist selected by the Church leadership to hospitalize, to secure proper treatment, and/or order injections, anesthesia, or surgery for my son or daughter as deemed necessary." Parent or Guardian's Signature_______________________________________ Print Name of Parent or Guardian____________________________________ Date________________________ |