Cliffview Youth Liability Form

Child's First Name

Child's Last Name

Prefered Name/Nickname

RELEASE OF ALL CLAIMS

In consideration for being accepted by Cliffview Church of God for participation in __ALL CLIFFVIEW CHURCH OF GOD EVENTS FOR YEAR LIST BELOW__, we (I) being 21 years of age or older, do for ourselves (myself) (and for and on behalf of my child-participant if said child if not 21 years of age or older) do hereby release, forever discharge and agree to hold harmless Cliffview Church of God and the directors thereof from any and all liability, claims or demands 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 the child-participant that occur while said child is participating in the above- described trip or activity.
Furthermore, we (I) (and on behalf of our (my) child-participant i under the age of 21 years) hereby assume all risk of personal injury, sickness, death, damage and expense as a result in participation in recreation and work activities involved therein.
Further, authorization and permission is hereby given to said church to furnish any necessary transportation, food and lodging for this participant.
The undersigned further hereby agrees to hold harmless and indemnify Cliffview Church of God, its directors, employees and agents, for any liability sustained by said church as the result of the negligent, willful or intentional acts of said participant, including expenses incurred attendant thereto.
If the participant has not attained the age of 21 years:
We (I) are the parent(s) or legal guardians of the participant and hereby grant our (my)
permission for him (her) to participate fully in said trip, and herby give our (my) permission to take said participant to a doctor or hospital and hereby authorize medical treatment, including but not in limitation to emergency surgery or medical treatment, and assume the responsibility of all medical bills, if any.
Further, should it be necessary for the participant to return home due to medical reasons, disciplinary action or otherwise, we (I) hereby assume all transportation costs.

Hospital Insurance

Yes

No

Insurance Company

Policy #

Physician Name

Emergency Phone Numbers

Father's Name

Mother's Name

Legal Guardian

Parent/Guardian phone they can be reached at

Date Input

Child/Children Information

Child's Name

Child's Age

Allergies or Medical Problems

Child Date of Birth

Address

Apartment, suite, etc.

City

State

Zip/Postal Code

TO WHOM IT MAY CONCERN:

The undersigned does hereby give permission for our (my) child

Child/Children's Name(s) (Please list all children covered)

to be covered by this liability form for the year listed below

Year

We (I) authorize and 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 advise 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.
The undersigned does also hereby 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 activities sponsored by Cliffview Church of God.

Signature

Date Signed