Liability/Medical Release Form - 2025

Grace Fellowship Church of Avon - Youth Group

Your name *

Email address *

Important Information

In consideration for being accepted by Grace Fellowship Church of Avon for participation in all ministry events from January 1, 2025 until December 31, 2025, we(I), being 21 years of age or older, do for ourselves (myself)(and for and on behalf of my child-participant if said child is not 21 years of age or older) do hereby release, forever discharge and agree to hold harmless Grace Fellowship Church of Avon and the directors thereof 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 the child-participant that occur while said child is participating in the above-mentioned youth ministry events.

Furthermore, we (I) [and on behalf of our (my) child-participant if under the age of 21 years] hereby assume all risk of 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, food and lodging for this participant.

The undersigned further hereby agree 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.

(If the participant has not attained the age of 21 years):
We (I) are the parent(s) or legal guardian(s) of this participant, and hereby grant our (my) permission for him (her) to participate fully in said ministry, and hereby give our (my) permission to take said participant to a doctor or hospital and hereby authorize medical treatment, including but not in limitation to emergency surgery or medical treatment, and assume the responsibility of all medical bills, if any.

Further, should it be necessary for the participant to return home due to medical reasons, disciplinary action or otherwise, we (I) hereby assume all transportation costs.

REQUIRED FIELDS ARE FOLLOWED BY A RED ASTERISK.

Please enter the participant's first and last name. *

2nd participant to enter?

Yes

3rd participant to enter?

Yes

4th participant to enter?

Yes

Parent(s) Telephone Number (format ###-###-####) *

Parent(s) Work Telephone Number (format ###-###-####)

Emergency Contact Name & Phone (format ###-###-####) *

Please enter the name of each participant and his/her physician and the physician's number (format of ###-###-####). *

Do you have hospitalization insurance *

Yes

Please list any allergies or special medical needs that any participant(s) may have.

By providing your name and submitting this form you are agreeing you are providing your signature electronically. *

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