Medical Release Form

Medical/Liability Release For 2024
Release of All Claims

In consideration for being accepted by North Monroe Baptist Church for participation in any and all Student Ministry activities during the calendar year 2024, this act is given for the entire year:
  • A. For the Participant: I/we, the undersigned, being 21 years of age or older, do for myself/ourselves hereby release, forever discharge and agree to hold harmless North Monroe Baptist Church, and the directors, officers, staff, employees, and/or volunteer members thereof from any and all liability, claim or demands for personal injury, sickness, death, property damage or expenses, of any nature whatsoever, which may be incurred by the undersigned that occur while I/we are participating in any activities or trips during said time period. Further, I/we hereby assume all risk of personal injury, sickness, death, damage, and expenses incurred attendant thereto.
  • B. For the responsible party of a participant: I/we, being the custodial parent(s), guardian or responsible party for a participate under the age of 21 years, do participant shown herein and my own behalf, hereby release, forever discharge and agree to hold harmless North Monroe Baptist Church, and the directors, officers, staff, employees, and/or volunteer members thereof from any and all liability, claim, or demands for personal injury, sickness, death, property damage or expenses, of any nature whatsoever, which may be incurred by the said participant while participant is involved in any activities or trips. Further, I/we hereby assume on behalf of said minor all risk of personal injury, sickness, death, damages, and expenses as a result of participation in recreation and/or work activities involved in said trips and/or activities. Further, the undersigned agrees to hold harmless said church as a result of the negligent, willful or intentional acts of the participant under the age of 21, including any expenses incurred attendant thereto. The undersigned declares that he/she is the legal guardian, parent, or custodian of the below written minor children or otherwise has authority to execute this release.
  • C. For both: I/we hereby grant my/our permission for said child to participate fully in said trips and/or activities and hereby give my/our permission for the church to take myself/participant to a doctor or hospital and hereby authorize medical treatment, including but not limited to, emergency surgery or medical treatments, and the undersigned assumes responsibility for all medical expenses, if any. If as an adult or a minor said participant is rendered unable to authorize medical treatment, the church through its agents is authorized to arrange for such treatment as may in their/its sole discretion be deemed appropriate. I/will agree to hold church harmless for such actions taken, whether rightly or wrongly but in good faith, and agrees to hold free and harmless and indemnify the church for such expenses incurred. This act is authorization for the church to provide and necessary transportation, food, and lodging for the participant. Should it be necessary to return a participant home due to medical reasons, disciplinary action, or otherwise, I/we hereby assume responsibility for all transportation cost and agree to reimburse the church for any such expenses incurred.

Participant Information

Parent/Guardian Information

Address of custodial parent/guardian
if different than participant

Please list two additional emergency contacts.
Note: One custodial parent/guardian signs in the presence of a witness for participants under age 21; otherwise participant should sign below:
I/we have read and understand the above and foregoing rules of conduct for participants and the release of liability/medical release form, and agree that I/the participant must abide by same and the directions of the leadership during the activities this act covers. I/we hereby agree to said release of liability/indemnity agreements contained herein.
*typed name above serves as your electronic signature.
*typed name above serves as your electronic signature.
Submit