IN CONSIDERATION for being accepted by Stockton Alliance Church (SAC) for participation in certain youth trips and/or activities, from January 1, 2024 to December 31, 2024 being twenty-one (21) years of age or older, on our/my behalf and on behalf of our/my minor child, do hereby release, forever discharge and hold harmless SAC, its officers, governing board, staff and agents, 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 participant while said participating in any youth trip or youth activity.
Furthermore, I/we, individually, on behalf of participant, hereby assume all risk of personal injury, sickness, death. Damage and/or expenses as a result of participating in recreation and/or work activities involved therein.
Further, authorization and permission is hereby given to SAC, its staff and/or agents, to furnish any necessary transportation, food and/or lodging for participant which may relate to an emergency situation. I/we agree to assume responsibility and reimburse SAC for any and all expenses incurred relating to said emergency situation.
The undersigned further agree(s) to hold harmless and indemnify SAC, its officers, governing board, staff or agents from any liability sustained by SAC as the result of negligent, willful or intentional acts of said participant, including expenses incurred attendant thereto.
I/we are the parent(s) or legal guardian(s) of said participant, and hereby grant permission for him/her to participate fully in said trip and/or activity. Further, permission is granted to take said participant to a doctor or hospital, and authorize medical treatment, including by not limited to emergency surgery. I/we further agree to assume responsibility of all medical bills related thereto, if any.
Should it be necessary for the child-participant to return home due to medical reasons, disciplinary action or otherwise, I/we hereby assume all necessary costs, including but not limited to transportation.
Participant’s
(FULL) Name: __________________________________________ Phone: ___________________
Father’s
Name (printed): __________________________________________ Phone: ___________________
Father’s
Signature: ______________________________________________ Date: ____________________
Mother’s
Name (printed): _________________________________________ Phone: ___________________
Mother’s
Signature: _____________________________________________ Date: _____________________
Legal Guardian’s
Name (printed): ________________________________________ Phone: ___________________
Legal Guardian’s
Signature: ____________________________________________ Date: ____________________
Home Address: ____________________________________________________________________________
City: ________________________________________ State: _____________ Zip Code: ________________
In case of an emergency, where the father, mother, and/or legal guardian cannot be contacted:
Emergency Contact Name: ___________________________________________________________________
Emergency Contact Number: ___________________________________ Relationship: __________________
Health Insurance? Y / N Health Insurance Company: _________________________________________
Health Insurance Phone: ____________________________ Physician’s Name: ________________________
History of Health Problems: ___________________________________________________________________
List of Allergies: ____________________________________________________________________________
Date of Last Tetanus Shot: ______________________