Liability Release Form

Release of All Claims

In consideration for being accepted by The Community Church of Glen Rock NJ for participation in  ____________________________________________________  We (I) being 21 years of age or older, do for outs selves ( myself and for and on behalf of my child/guardian – participant if said child is not 21 years of age or older, do hereby release, forever discharge and agree to hold harmless the Community Church of Glen Rock, NJ 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 a(I) (and on behalf of our (my) child-participant if under the age of 21 years) herby assume all risk of personal injury, sickness, death, damage and expense as a result of participation in recreation and work activities involved therein.

Further, authorization and permission is herby given to said church to furnish any necessary transportation, food and lodging for this participant.

The undersigned further hereby agree to hold harmless and indemnify said church, its directors, employees a d 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.

(If the participant has not attained the age of 21 years):

We (I) are /am the parent’s) or legal guardian(s) of the participant, and hereby grant our (my) permission for him (her) to participate fully in said trip, and herby give our (my) permission to take said participant to a doctor or hospital and herby authorize medical treatment, including, but not in limitation to emergency surgery or medial treatment, ad assume responsibility of all medical bills if any.

Further should it be necessary for the participant to return home due to medial reasons, disciplinary action or otherwise, we (I) herby assume all transportation costs.

Name of participant (PRINT) _____________________________________________

Parent(s) Home Phone: ______________________   Cell phone_____________________

Health Insurance Company _________________________________________________

Policy Number ___________________________________________________________

Physician Name and phone   ________________________________________________

Emergency contacts and phone numbers ________________________________________

__________________________________________________________________________

Only Participants must sign if 21 years or age or older.  If under 21, a parent signature is required.

Parent Signature ______________________________________

Participant signature, if age 21 ___________________________

Trip Participant Only

I agree to abide by the rules of conduct for participants as well as the directions of the leadership of the trip.  ______________________________________________________  ( participant’s signature)