Medical and Liability Release Form
Gethsemane Church of Christ
5146 Mechanlcsville Turnplke Mechanlesville, VA
Authorization of Consent for Treatment of Minor/ Permission to participate in
off-site activities/ Permission to be photographed
It Is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care being required, but Is given to provide authority and power on the part of our aforesaid agent(s) to give specific consent to any and all such diagnosis, treatment or hospital care which the aforementioned physician in the exercise of his or her best judgment may deem advisable.
My student Is allowed to attend events sponsored by Gethsemane Church of Christ that take place off campus, and my student Is allowed to be transported to these events by a Gethsemane Church of Christ church bus, or volunteers authorized to drive their personal vehicles for the specific event. I understand the nature of these events, and I will not hold Gethsemane Church of Christ Ilable for any injury or accident that happens to my student during an event.
Permission for my student to be photographed (Initial one of the two options below): My child is allowed to be photographed while participating in events and activities sponsored by Gethsemane Church of Christ's Student Ministry. I understand that these photos could be displayed on bulletin boards at Gethsemane Church of Christ, or used in any Gethsemane Church of Christ publicity, induding any associated Internet websites.
This authorization shall be in effect from