Permission, Consent, & Liability Release | Leesburg Christian Church | 6005 KY 1842 N Cynthiana, KY 41031

Today's Date: *

I acknowledge that this Permission, Consent, & Liability Release is valid only for the calendar year in which is has been filled out. (Jan.1 -Dec.31 2023) *

I do

Participants Full Name *

Age *

Birthdate *

Address *

Phone *

Parent/Guardian Name(s) *

Cell Phones *

To Whom it May Concern

The undersigned hereby gives permission for my child to attend and participate in Leesburg Christian Church activities, events, and retreats during the year. *

Liability Release

In consideration of Leesburg Christian Church (LCC) allowing the Participant to participate in Student/ Children’s activities, we (I), the undersigned, do hereby release, forever discharge and agree to hold harmless Leesburg Christian Church, its directors, employees, volunteers and agents (collectively herein the “Church”) from any and all liability, claims or demands for accidental 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 Participant while involved in the youth activities. We (I), the parent(s) or legal guardian(s) of this Participant, hereby grant our (my) permission for the Participant to participate fully in LCC’s activities, including trips away from the church premises.

Furthermore, we (I) [and on behalf of our (my) minor Participant(s)] hereby assume all risk of accidental personal injury, sickness, death, damage, and expense as a result of participation in recreation and work activities involved therein. Authorization and permission is hereby given to the Church to furnish any necessary transportation (within the limitations of church insurance and the law), food, and lodging for the Participant. The undersigned agree(s) to hold harmless and indemnify the Church for any liability sustained by the Church as a result of negligent, willful or intentional acts of Participant, including expenses incurred attendant thereto.

Medical Treatment Permission

We (I) authorize an adult, in whose care the minor Participant has been entrusted, to consent to any emergency x-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment and hospital care to be rendered to the minor Participant under the general or special supervision and on the advice of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital or emergency care facility. 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 minor Participant pursuant to this authorization.

Early Return Home Policy

Should it be necessary for our (my) child or youth to return home due to medical reasons, disciplinary action, or otherwise, the undersigned shall assume all transportation costs and responsibility.

Transportation Permission

The undersigned does also hereby give permission for our (my) youth to ride in any vehicle driven by an approved ADULT chaperone while attending and participating in activities sponsored by the Church. My child and I understand that SEAT BELTS SHALL BE WORN AT ALL TIMES during transportation.

Photograph/Video Permission

All photos, videos, and audio tapes of my child captured by LCC is also for promotional purposes such as brochures, videos, web pages, etc.

Medical Information

Medical Insurance Company *

Policy/Group ID# *

Allergies or medical conditions *

Prescriptions or Medications *

If needed, do you authorize administering pain medication (Tylenol, Advil, Ibuprofen) to your child? *

Yes

Emergency Contact Information

Name of emergency contact if Parent/Guardian cannot be reached: *

Relationship to participant *

Emergency Contact Phone Number *

STUDENT/PARTICIPANT AND PARENT/GUARDIAN SIGNATURES

My signature on this Annual Permission / Consent / Liability Release Form is an acknowledgement that I have read and understand these guidelines. I recognize that this is a permission slip, medical release, liability release, and covenant for the year. I commit to abide by the provisions of this Release Form.

Participant Signature *

clear

Parent/Guardian Signature *

clear