Medical Release - Authorization for Church Outing - Waiver for Liability (for Minors)

Purpose of Activity: Acquire the Fire
Destination: UMASS Campus, Hadley, MA
Date Leaving: September 26, 2008     Day: Friday      Time: 2:00 PM
Leaving From: Harvest Church, 303 Grooms Road, Clifton Park, NY
Date Returning: September 27, 2008  Day: Saturday   Time: 11:59 PM
Pick up at: Harvest Church, 303 Grooms Road, Clifton Park, NY
Supervisor(s): Paulie & Nikki Tebbano

I, ________________________ of _______________________, City of __________________________, County of __________________, State of ____________________, parent/legal guardian of ____________________, For myself and for my heirs, legal representatives, and assigns do hereby release HARVEST CHURCH of 303 Grooms Road, City of Clifton Park, County of Saratoga, State of New York, their legal representatives, successors and assigns, to never institute any suit or action at law or in equity against HARVEST CHURCH by reason of any claim that I may now have or may hereafter acquire relating to the administering of first aid by the staff or volunteer nurses from any responsibilities in an emergency or in the administering of medications (e.g. Tylenol or Aspirin) to my child, ______________________. Further, in the event of an emergency where medical personnel is required, I give my permission to the church staff to obtain the services of the necessary medical personnel or licensed physician. In executing this release I expressly reserve any and all rights, causes of action, claims, and demands against any person, firm, or corporation other than HARVEST CHURCH.

I further state that ___________________ is allergic to the following medications/procedures: _________________________________________

_____________________________________
Releasor - Parent/Legal Guardian Signature

Emergency Contacts: (PLEASE PRINT)
NAME: ______________________________________
PHONE NUMBERS: HOME: _______________ WORK: _____________
NAME: ______________________________________
PHONE NUMBERS: HOME: _______________ WORK: _____________

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