Crossroads Youth & Kids Ministries 8901 S. Shields Blvd ...

Crossroads Youth & Kids

Ministries

8901 S. Shields Blvd.

Oklahoma City

OK. 73149

2015 Liability and Medical Release Form

In consideration for being accepted by Frist Assembly of God Church OKC, Inc. DBA: Crossroads Church for

participation in all church sponsored events for 2015, we (I), being 18 years of age or older, do for ourselves (myself) [and

for/on behalf of my child/participant, if said child is not 18 years of age or older] do hereby release, forever discharge and

agree to hold harmless Crossroads Church, its members, officers, directors, employees, agents, representatives, and

successors and assigns thereof from any and all liability, claims or demands for personal injury, sickness or death, as well as

property damage and expense, of any nature, which may be incurred by the undersigned and the child/participant that

occur while said child is participating in the above mentioned events. Furthermore, we (I) [and for/on behalf of my

child/participant, if said child is not 18 years of age or older] hereby assume all risk of personal injury, sickness, death,

damage, and expense (including attorney fess) as a result of participation in recreation and work activities involved therein.

Authorization and permission is hereby given to said church to furnish any necessary transportation, food and lodging for this

participant. The undersigned further agrees to hold harmless and indemnify said church, 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. I understand that a permission slip must be completed and signed for each

event I wish to attend. This form DOES NOT replace the permission slip.

If participant is under 18:

I (we) the parents(s)/ legal guardian of this participant, hereby grant permission for him/her to participate fully in

said events, and hereby give permission for said participant to be taken to a doctor or hospital if deemed necessary and

hereby authorize medical treatment, including but not limited to emergency surgery or medical treatment, and assume the

responsibility of all medical bills of such treatment. Further, should it be necessary for the participant to return home due to

medical reasons, disciplinary action or otherwise, I (we) hereby assume all transportation costs. I also understand that I am

responsible to notify the youth pastor or kids pastor if a change in legal guardianship during during the course of 2015.

If the participant is over 18:

I, the undersigned, give my express consent to the authorized agents of the above church to act on my behalf,

should I not be able to make the decisions named above for myself.

Name (PRINT) ________________________________________________________________________

Student Signature (if over 18)___________________________________ Date _________________________

Parent/ Legal Guardian Signature

(if participant is under 18) _____________________________ Date _________________________

Contact Numbers

Home Ph. # (405) _____-______

Work Ph. # (405) _____-______

Cell Ph. #

(405) _____-______

Health Insurance Company ___________________________ Policy # ______________________

If the above numbers cannot be reached please contact:

_____________________________________________________________ Ph. # (405) _____-______

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