2020/21 Youth Liability Release & Insurance Info

March 13, 2020
HPCC
Forms

2020/21 HPCC Youth General Liability Release & Insurance Info

This release is valid for general HPCC Youth Ministry events from June 1, 2020 through August 31, 2021.
General Release of Liability
In consideration for being accepted by Highland Park Community Church for participation in their Youth Ministries 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 the above-described trip or activity. 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 Ministries 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, 2020. (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, 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
Participant Information
Name Of Participant*
First Last
Gender*
- Male
- Female
2020-21 Grade*
(Grade for 2020/21 school year)
Parent/Guardian Contact Info
First Parent/Guardian Name*
First Last
Home Phone*
Work Phone*
Cell Phone*
Second Parent/Guardian Name*
First Last
Home Phone*
Work Phone*
Cell Phone*
Home Address*
Street Address Address Line 2 City State ZIP Code
Insurance Information
Insurance Company*
Insurance Company Policy Number*
Emergency Contact other than above*
First Last
Emergency Contact Phone*
Signatures
TWO SIGNATURES ARE REQUIRED - Either both parents, or a parent/guardian and a witness. STUDENT SIGNATURE REQUIRED ONLY FOR YOUTH OVER 18. Signatures are NOT required for every location, only for two (2).
Father's Signature
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.
Date
Date Format: MM slash DD slash YYYY
Mother's Signature
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.
Date
Date Format: MM slash DD slash YYYY
Legal Guardian's Signature
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.
Date
Date Format: MM slash DD slash YYYY
Witness Signature
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.
Date
Date Format: MM slash DD slash YYYY
PARTICIPANTS Signature (if age 18)
Date
Date Format: MM slash DD slash YYYY

Save and Continue Later

2020/21 Youth Liability Release & Insurance Info

2020/21 HPCC Youth General Liability Release & Insurance Info

General Release of Liability

Participant Information

Parent/Guardian Contact Info

Insurance Information

Signatures

One Comment

Adam Doyle

Add a Comment Cancel