Immanuel Church Liability Waiver
Participant (s) Name
Please use this feild for all participants with in a family
Emergency Contact and Number
Insurance Company Policy Number Plan #
Current Medications: Allergies Special Instructions
PLEASE SIGN BELOW: WAIVER/EXCLUSION CLAUSE: I, the undersigned parent(s)/guardian(s) listed above have temporarily entrusted the care of the participating minor to the care of Immanuel Church and the leadership of the Children’s Ministry. In participating in an activity at Immanuel Church, I the parent(s)/guardian(s) understand that my child listed above and I in attending any program and using the facilities does so at his/her/my own risk. Immanuel Church, and its board, members, employees and agents, shall not be liable for any damage whatsoever arising from any personal injury or property loss sustained by participant and his/her/my family in or about any programs on or off premises. Participants and parents assume full responsibility for all injuries and damages which may occur in or about any programs on or off premises and he/she/I does hereby fully and forever release, discharge and hold harmless Immanuel Church, all associated facilities and its board, members, employees and agents from any and all claims, demands, damages, rights of action, present or future resulting from or arising out of any person's participation in any programs or use of its facilities.
CONSENT: I, the undersigned parent(s) of/guardian(s) of/participant verify that they are in good health and I assume the health responsibility for the participant and do hereby grant authority to the staff of Immanuel Church to render judgment concerning medical assistance or hospital care in the event of an accident or illness during my absence or after reasonable attempts are made to contact me. I hereby authorize Immanuel Church and its leadership to utilize any and all photographs, pictures or other likeness of me as they deem appropriate in its promotional materials.
I agree to and have read all conditions
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