RELEASE FORM FOR LIFEPOINTE CHURCH YOUTH ACTIVITIES

Parent/Guardian Permission and Medical Statement

I hereby certify that my son/daughter has my approval to attend events sponsored by or associated with LifePointe Church. I understand that there may be activities my son/daughter are involved in that will be around water (i.e. swimming pool, lake, ocean) and that there may not be any trained lifeguards on duty. I understand all reasonable care will be taken to avoid accident or injury to my child while on all trips and events with the LifePointe Church Youth Program and release the paid and/or volunteer staff of LifePointe Church and the paid and/or volunteer staff from any event attended by the LifePointe Church Youth Group from any and all liability. In the event of medical emergency, I understand every effort will be made to contact me or the authorized person listed on this form. In the event we cannot be reached, I grant permission to the staff of the trip or event to secure medical and/or surgical care for my child named above. I understand that LifePointe Church does not carry medical insurance for its youth activity participants and agree to accept the expense of emergency care through my medical insurance and/or personal resources.

Student's Name

First Name

Last Name

Student's DOB

YYYY

Gender

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home Phone

(###)

###

####

Parent Day Phone

(###)

###

####

Parent Cell Phone

(###)

###

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Medical Information

Policy Holder’s Name

First Name

Last Name

Insurance & Policy Number

Child’s Allergies/Illnesses

Additional Contact Person #1

First Name

Last Name

Additional Contact Person #1

(###)

###

####

Additional Contact Person #2

First Name

Last Name

Additional Contact Person #2

(###)

###

####

Additional Contact Person #3

First Name

Last Name

Additional Contact Person #3

(###)

###

####

List of any ongoing prescription medications being taken:

Describe any special needs due to disability. In participating with the LifePointe Church Youth Group, I the undersigned, understand that I willfully and freely participate in this program under my own volition/personal responsibility and liability. As such, I fully understand that I participate solely under my own liability/family insurance plan germane to any risk factor that may arise during a trip or event, either foreseeable or unforeseeable, including but not limited to: medical emergency, hospitalization, accident, dismemberment or death. I further understand and agree to hold harmless in law and in equity any of the LifePointe Church or event staff, or other individuals or congregations participating in these programs, for any negligence, or personal/group satisfaction/dissatisfaction pertaining to any aspect of the program or travel related to this trip.