Liability Release Form - Youth Activities

Liability Release Form (Youth Activities) 

 Child's Information: 

 

 

 Name: ______________________________ 

 

 

 Date of Birth: ____/____/____ 

 

 

 Address: ________________________________________________________ 

 

 

 Parent/Guardian Information: 

 

 

 Name: ______________________________ 

 

 

 Phone: 

 

 

 

 (H) ______________________________ 

 

 

 (W) ______________________________ 

 

 

 (M) ______________________________ 

 

 

 

 Emergency Contact: 

 

 

 Name: ______________________________ 

 

 

 Phone: 

 

 

 

 (H) ______________________________ 

 

 

 (W) ______________________________ 

 

 

 (M) ______________________________ 

 

 

 

 Activity Details: 

 

 

 Name of Activity: ______________________________ 

 

 

 Date(s): ____/____/____ to ____/____/____ 

 

 

 Location: ______________________________ 

 

 

 Medical Information: 

 

 

 Doctor's Name: ______________________________ Phone: ______________________________ 

 

 

 Any medical conditions or allergies: ______________________________________________ ______________________________________________ 

 

 

   

 Consent and Release: I, the undersigned parent/guardian of the above-named child: 

 

 

 Give permission for my child to participate in the above-named activity. 

 

 

 Understand and acknowledge that this activity involves risks. 

 

 

 Authorise Generocity Church to obtain any necessary medical treatment for my child in case of injury or illness, and agree to pay for any such medical treatment. 

 

 

 Release Generocity Church, its staff, and volunteers from any liability related to my child's participation in this activity. 

 

 

 Photo/Video Release: □ I give permission for Generocity Church to use photos/videos of my child for promotional purposes. □ I do not give permission for photos/videos of my child to be used. 

 Signature of Parent/Guardian: ______________________________________________ Date: ____/____/____