~Calvary Baptist Church~

15880 Crest Drive Woodbridge, VA 22191 (703) 670-7217

Youth Liability Consent Form

I, the parent or legal guardian of__________________________________________________

(Participant’s name)

give Calvary Baptist Church permission to transport my child-participant to youth sponsored

events.

I, being 21 years of age or older, do, on behalf of my child-participant, hereby release, forever discharge and agree to hold harmless Calvary Baptist Church and its representative 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 participant while participating in said event or activity.

Additionally, I, the undersigned, hereby agree to hold harmless and indemnify said church, its directors, employees and agents from any liability due to injuries sustained as the result of negligent, willful or intentional acts on the part of the participant.

Finally, in case of injury, I hereby grant permission to transport the participant to a doctor or hospital and hereby authorize medical treatment, up to and including emergency surgery. I further agree to assume the responsibility of any resultant medical bills.

I have read the foregoing and understand and agree to abide by its terms and conditions.

Name of Participant: _________________________________________________________________

Signature of Parent or Legal Guardian: ___________________________________Date:_____________

Address: __________________________________________________________________________

__________________________________________________________________________________

Phone: _______________________________ cell phone: ___________________________________

Email: _________________________________

In case of an emergency, contact: _____________________________________________________

Emergency Contact Phone: _______________________________

Name of Physician: _______________________________________________________

Physician’s Number: _______________________________

Insurance Carrier: __________________________________________________________________

Policy Number: _______________________________________

Phone: __________________________________________