EMMANUEL BIBLE CHURCH
EMMANUEL YOUTH MINISTRIES
SINGLE
EVENT RELEASE FORM
2008-2009
Please download, complete and return this form to Emmanuel Youth Ministries
I am giving permission for:
______________________________________________________________________
to attend the following event:
__________________________________________________________________
Date(s): __________________________________________________________
In the event that he/she is injured while under
the care of Emmanuel Bible Church
and its representatives and requires the attention of a doctor, I hereby consent
to
and will be responsible for any medical treatment as deemed necessary by a
licensed physician.
I further agree to hold the licensed physician, the medical facility, Emmanuel
Bible Church
and its representatives free and harmless of any claim, demands, or suits for
damages arising from
the authorization and provision of such medical treatment.
I understand the nature of these events and do hereby release Emmanuel Bible
Church
and its representatives from any liability due to accident or injury incurred by
my child.
Medical Conditions:
___________________________________________________________________________
_____________________________________________________________________________________________
Medications being taken by my child:
____________________________________________________________
_____________________________________________________________________________________________
Allergies (medication/food/environment):
_______________________________________________________
_____________________________________________________________________________________________
Special Needs: _______________________________________________________________________________
Emergency Contact Name and Telephone:
_______________________________________________________
_____________________________________________________________________________________________
Insurance Company and Policy Number:
_________________________________________________________
_____________________________________________________________________________________________
Signature of Parent/Guardian:
_________________________________________________________________
Date:
_____________________________________________________________________________