Parental Consent and Liability Release Form

PARTICIPANT’S NAME ____________________________________AGE _______________________BIRTH DATE _______________

ADDRESS__________________________________________________________________________________________________

PHONE ___________________________ SCHOOL _________________________________________________ GRADE _________

PARENT(S)/GUARDIAN NAME(S) ________________________________________________________________________________

WORK PHONE(S)/ CELL PHONE(S)_____________________________________/________________________________________

TO WHOM IT MAY CONCERN:

The undersigned do(es) hereby give permission for our (my) child(ren):

_________________________________________________________________________________________ (“Participant”), to attend and participate in attending _________________________________ sponsored by the First Presbyterian Church of Pompano Beach, Florida on:___________________________________2008

LIABILITY RELEASE: In consideration of First Presbyterian Church of Pompano Beach, Florida allowing the Participant to participate in this youth ministry activity, we (I), the undersigned, do hereby release, forever discharge and agree to hold harmless First Presbyterian Church of Pompano Beach, Florida, 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 the Participant while involved in the children/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 youth ministry 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.
Further, authorization and permission is hereby given to said Church to furnish any necessary transportation (within the limitations of church insurance and the law), food and lodging for this Participant. The undersigned further hereby agree to hold harmless and indemnify said Church 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.

MEDICAL TREATMENT PERMISSION: We (I) authorize an adult, in whose care the minor 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 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 child or youth 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 First Presbyterian Church of Pompano Beach, Florida.

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Medical Insurance: YES _______ NO _______ Insurance Company: ______________________________________________

Policy/Group ID#: ____________________________________ Emergency Phone #s in case parent/guardian cannot be reached:

________________________________________________________________________________________________________

Allergies or Medical Conditions: _____________________________________________________________________________

Parent/Guardian Signatures ________________________________/_________________________________ Date ___________