Juvenile Van Ministry Rider Permission Slip

Permission to ride Lannius Church of God van to and from church

Days: Every Sunday AM & Wednesday PM

Times: Times will vary due to pick up

Child's Name

First NameLast Name

Parent's/Guardian's Name

First NameLast Name

Parent/Guardian's Email*

example@example.com

Parent/Guardian's Phone Number

Please enter a valid phone number.

Parent/Guardian's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

I do herby release, forever discharge and agree to hold Lannius COG 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 participant that occur while said person is participating in the above-described and indemnify said church, it directors, employees, and agents for ANY liability sustained by said acts of said participant, including financial expenses incurred attendant thereto.

I agree with the above statement.*

YesNo

You do know by selecting "NO", your child/children are NOT allowed to ride the van to and from church. Please select "YES" to continue!

The undersigned further consents to the administration of first-aid and / or doctor’s care, or any other form of medical treatment necessitated by illness or injury that may require the same and assumes all financial obligations resulting from such care. In the event of the necessity of such care or treatment as heretofore described, the undersigned agrees to hold harmless and indemnify said church, its directors, employees and agents from any acts of malfeasance, and/or failure to act on the part of those chosen to administer medical care on behalf of the participant.

Child's Name

First NameLast Name

Insurance Policy Holder's Name*

Insurance Company*

Policy Number*

Group Number (if applicable)*

Contact's Phone Number

Please enter a valid phone number.

I have read, understood, and answered all the above questions and responses to the best of my ability. I do herby release, forever discharge and agree to hold Lannius COG 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 participant that occur while said person is participating in the above-described and indemnify said church, it directors, employees, and agents for ANY liability sustained by said acts of said participant, including financial expenses incurred attendant thereto.

Parent/Guardian's Signature*

Parent/Guardian's Printed Name*

First NameLast Name