Liability and Health Form

In consideration for being accepted for participation in as 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 LAKE HOUSTON METHODIST CHURCH and the directors there of 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-described trip or activity.

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.

Further, authorization and permission is hereby given by the undersigned to said church to photograph/video participant and use the photo/video and likenesses of participant in any manner or media that it chooses, including but not limited to newsletters, social media, websites, or advertising.

PHOTO/VIDEO OPT OUT

I do NOT GIVE PERMISSION to use my participant's likeness for purpose above.

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 trip, 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 responsibility for all transportation cos

Participant's Name*

First NameLast Name

Parent/Guardian Signature*

Phone Number*

Please enter a valid phone number.

Insurance Company:
Policy Number:

Physician:
Physician's Phone Number

LIABILITY RELEASE AND PARENTAL CONSENT FORM LHMC CHILDREN/STUDENT MINISTRY ACTIVITIES

PARTICIPANT HEALTH INFORMATION FORM LHMC CHILDREN/STUDENT MINISTRY ACTIVITIES