2022/23 Youth Liability Release & Insurance Info

March 13, 2020
HPCC
Forms

2022/23 HPYouth General Liability Release & Insurance Info

Valid for event participation between June 1, 2022 and August 31, 2023.

THIS RELEASE IS VALID FOR GENERAL HPYouth MINISTRY EVENTS FROM June 1, 2022 THROUGH AUGUST 31, 2023.

PARTICIPANT INFORMATION

PARTICIPANT NAME(Required)

First Last

SEX(Required)

Male

Female

2022-23 GRADE(Required)

(Grade for 2022/23 school year)

IS STUDENT/PARTICIPANT AGE 18 OR OLDER?(Required)

PARENT/GUARDIAN CONTACT INFO

FIRST PARENT/GUARDIAN NAME(Required)

First Last

HOME PHONE(Required)

WORK PHONE(Required)

CELL PHONE(Required)

SECOND PARENT/GUARDIAN NAME

First Last

HOME PHONE

WORK PHONE

CELL PHONE

HOME ADDRESS(Required)

Street Address Address Line 2 City State ZIP Code

INSURANCE & EMERGENCY CONTACT INFORMATION

INSURANCE COMPANY(Required)

If uninsured, enter NONE.

INSURANCE POLICY NUMBER(Required)

If uninsured, enter NONE

EMERGENCY CONTACT OTHER THAN PARENT/GUARDIAN(Required)

First Last

EMERGENCY CONTACT: RELATIONSHIP TO PARTICIPANT

EMERGENCY CONTACT: PHONE(Required)

GENERAL RELEASE OF LIABILITY

CONSENT TO RELEASE OF LIABILITY(Required)

In consideration for being accepted by Highland Park Community Church for participation in their HPYouth Ministry Events we (I) being 18 years of age or older, do for ourselves (myself) (and for and on behalf of my child-participant if said child is not 18 years of age or older), do hereby release, forever discharge and agree to hold harmless Highland Park Community Church and the directors thereof from any and all liability claims or demands for personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the child-participant, that occur while said child is participating in HPYouth trips or activities.

Furthermore, we (I) [and on behalf of our (my) child-participant if under the age of 18 years] HEREBY ASSUME ALL RISK of personal injury, sickness, death, damage and expense as a result of participation in recreation and work activities involved therein.

Authorization and permission is hereby given to said church to FURNISH ANY NECESSARY TRANSPORTATION, FOOD, AND LODGING for this participant.

PICTURES taken by HPCC staff are property of HPCC Youth Ministry and may appear on the website or Facebook page or other social media sites.

The undersigned further hereby AGREE TO HOLD HARMLESS AND INDEMNIFY said church, its directors, employees, and agents, for any liability sustained by said church as the result of the negligent, willful, or intentional acts of said participant, including expenses incurred attendant thereto. This form is valid for all Highland Park Youth Ministry Events UNTIL THE RELEASE DATE OF AUGUST 31, 2023.
(If the participant has not attained the age of 18 years):

We (I) are the parent(s) or legal guardian(s) of this participant, and hereby grant our (my) PERMISSION for him (her) TO PARTICIPATE FULLY in said trip/event, and hereby give our (my) permission to take said participant to a doctor or hospital and hereby AUTHORIZE MEDICAL TREATMENT, including, but not in limitation to emergency surgery or other medical treatment, and assume the responsibility of all medical bills, if any.

FURTHER, should it be necessary for the participant to return home due to medical reasons, disciplinary action, or otherwise, we (I) hereby assume all transportation costs for student and an adult chaperone of the same sex

I agree to the Release of Liability stipulated above

REQUIRED SIGNATURES

TWO SIGNATURES ARE REQUIRED for minor participants - Either both parents, or a parent/guardian and a witness. ONLY STUDENT/PARTICIPANT SIGNATURE REQUIRED FOR THOSE OVER 18.

AUTHORIZED SIGNATURE #1(Required)

Use your mouse if you are using a computer to sign the above field. If you are using a touchscreen or a smartphone, you can use your finger to sign.

SIGNATURE 1: RELATIONSHIP TO STUDENT(Required)

DATE(Required)

AUTHORIZED SIGNATURE #2 (CANNOT BE SAME AS SIG #1)(Required)

Use your mouse if you are using a computer to sign the above field. If you are using a touchscreen or a smartphone, you can use your finger to sign.

SIGNATURE 2: RELATIONSHIP TO STUDENT(Required)

DATE(Required)

PARTICIPANT'S SIGNATURE (FOR AGE 18 OR OLDER)(Required)

DATE(Required)

2022/23 Youth Liability Release & Insurance Info

2022/23 HPYouth General Liability Release & Insurance Info

PARTICIPANT INFORMATION

PARENT/GUARDIAN CONTACT INFO

INSURANCE & EMERGENCY CONTACT INFORMATION

GENERAL RELEASE OF LIABILITY

REQUIRED SIGNATURES

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