Application / Medical Release Form

The Charthouse
Missions Participation
Parent Permission/Medical Release
And Indemnification Agreement
http://missionforchrist.blogspot.com/

I, the undersigned, am the parent/legal guardian of the minor child named below and am at least 18 years of age. I am signing this document (release) on my own behalf and on behalf of my child.

I hereby give permission for my child, _______________________________________________, (print name of child)
to participate in missions with Belview Baptist Church. I understand that there are risks involved in missions. By signing this release, my child and I agree to accept any and all such risks and voluntarily elect to participate in this mission. We understand that due to these risks the conduct of my child is of utmost importance. My child agrees to abide by all rules of conduct whether written or spoken. I understand that if my child should behave inappropriately or become disruptive during this mission, that I the parent/legal guardian will be responsible for all cost involved in returning my child to their home.


In consideration of allowing my child to participate in missions with Belview Baptist, I assume all risks associated with my child’s participation. Additionally, I hereby agree to hold harmless, release, defend and indemnify Belview Baptist and/or claims I may make arising from injury or death to persons or damage to property in any way related to my child’s participation in this mission, including those injuries and damages caused by any released party’s alleged or actual negligence. I also agree to defend and indemnify each released party for any and all such claims a third party may make which are in any way related to my child’s participation.

I authorize any released party to call for medical care for my child and/or to transport my child to a hospital or other medical facility if, in the opinion of such released party, medical attention is needed for my child. I understand that an effort will be made to locate me in the event of such an emergency, but, if it is not possible to locate me, I authorize medical care providers to provide any emergency care to my child. I agree that, upon my child’s transport to any such hospital or other medical facility, no released party shall have any further responsibility for my child. Further, I agree to pay all costs associated with such medical care and related transportation provided to my child and shall indemnify each released party from incurred costs therefore.

I consent and authorize the use and reproduction, for any purpose and without compensation, of all images taken of child while engaged in above listed activity.

I promise that I will inform Belview of any known medical condition that my child may suffer which may affect my child’s ability to participate in this mission. I will also provide any medications that may be necessary for my child while he participates.

List any important health information (e.g. prescription medications, allergies, dietary restrictions, chronic physical problems, etc.):

_______________________________________________________________________________________________________________

List any special habits, needs, or fears:

_______________________________________________________________________________________________________________

I HAVE CAREFULLY READ THIS RELEASE, UNDERSTAND ITS CONTENTS,
AND SIGN IT WITH FULL KNOWLEDGE OF ITS SIGNIFICANCE.

Executed this _______ day of _____________________________, 200___.


______________________________________________ ___________________________________________
Printed Name of Parent/Legal Guardian Signature of Parent/Legal Guardian


_________________________________________________________ _____________________________________________________
Emergency Contact Name Date Emergency Contact Phone


Created on 12/16/2004 1:25:00 PM