Parental Consent & Liability Release:
The General Release/Hold Harmless Agreement previously signed remains in full force and effect as if set forth herein at length. The undersigned authorizes a representative of the Church to consent to any x-ray examination, anesthetic, medical or surgical or dental diagnosis or treatment, and hospital care, to be rendered to the minor under the general or special supervision and on the advice of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital.
The undersigned, both individually and on behalf of the above-captioned child (“undersigned”) shall be liable and agree(s) to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child pursuant to this authorization.
The undersigned does also hereby give permission for our/my child to ride in any vehicle designated by the adult in whose care the minor has been entrusted while attending and participating in activities sponsored by Ebenezer Bible Fellowship Church.
The undersigned does hereby release, forever discharge and agree to hold harmless the Church 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.
The undersigned hereby assumes all risk of personal injury, convenience, annoyance, 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 the participant.
The undersigned further hereby agree(s) to hold harmless and indemnify said church, its directors, employees and agents, for any liability sustained by said Church as the result of the acts of said participant, including expenses incurred attendant thereto.
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 activity and hereby give our/my permission to take said participant to a doctor or hospital and hereby authorize medical treatment, including but not limited 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.
I understand that the Church will not be liable whether or not I am insured. It is my responsibility and legal obligation to reimburse the Church for any expenses incurred. The undersigned authorizes the Church to act as the undersigned agent in presenting this agreement to any qualified medical/dental practitioner and the undersigned will not hold the Church or such practitioners liable for treatments rendered.
This authorization will remain effective while the undersigned is en route to or from, whether participating, observing, or standing by any Church program or activity.
The undersigned has read, understood and consents to the terms of this document and confirms that it has read, understood and consents to the general release hold-harmless agreement previously provided to the Church.
The undersigned warrants to the Church that all of the information given on this form as well as the General Release/Hold Harmless Agreement is true, current and accurate.