Print Form

LIABILITY RELEASE FORM
January 1, 2019 to December 31, 2019

IN CONSIDERATION for being accepted by Stockton Alliance Church (SAC) for participation in certain youth trips and/or activities, from January 1, 2019 to December 31, 2019 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: ______________________