ORGANIZED ONE-ON-ONE YOUTH MENTORSHIP RELEASE FORM

LIABILITY RELEASE: In consideration of Lakewood Baptist Church allowing my child to participate in an Organized One-on-One Mentorship, I, the undersigned, do hereby release, forever discharge and agree to hold harmless Lakewood Baptist Church, its pastors, directors, employees, and Student Volunteers (collectively herein the “Church”) from any and all liability, claims or demands for accidental personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and my child while involved in the Organized One-on-One Youth Mentorship. I, the parent or legal guardian of my child, hereby grant my permission for my child to participate fully in an Organized One-on-One Youth Mentorship. Furthermore, I, on behalf of my minor child, hereby assume all risk of accidental personal injury, sickness, death, damage and expense as a result of participation in recreation and work activities involved therein. The undersigned further hereby agrees to hold harmless and indemnify said Church for any liability sustained by said Church as the result of the negligent, willful or intentional acts of my child, including expenses incurred attendant thereto.

MEDICAL TREATMENT PERMISSION: I authorize the Student Volunteer in whose care my child has been entrusted, to consent to any emergency x-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment and hospital care, to be rendered to my child under the general or special supervision and on the advice of any licensed physician or dentist on the medical staff of a licensed hospital or emergency care facility in any state or the District of Columbia. The undersigned shall be liable and agrees to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child pursuant to this authorization