digital signature waiver tours

RELEASE, INDEMNITY AND CONSENT TO MEDICAL TREATMENT

Please Fill A Waiver Form for each Child that is attending this trip: If your Child is 18 or younger, you must have this form completed for them to be allowed to attend this trip.

The Emergency Contacts at the end of this form ideally should be the Parents/Guardians of the child attending Winterfest, but MUST be somebody who is able to be contacted in the event of an emergency.

"I (First Name, Last Name) Please Fill (Parent's Name) Below in field Box:

Parent First and last name: * Please enter your name.

Am the Parent of (First Name, Last Name) (Type Child's Name below in the field Box)

Child First and last name: * Please enter your name.

I (Parent indicated above) GIVE MY PERMISSION FOR MY SAID CHILD (indicated above) TO PARTICIPATE IN THE LAUREL CHURCH OF CHRIST YOUTH GROUP TRIP TO GATLINBURG, TN FOR WINTERFEST 2017.

To the best of my knowledge said child is physically fit to engage in such activity and is not suffering from any disease or injury which needs to be disclosed for purposes of this release.

In the event said child should become ill or injured during the course of this trip, I direct any adult who shall have care and custody over said child to contact me if at all possible before authorizing major medical treatment of said child. HOWEVER, IF ANY ADULT HAVING CARE AND CUSTODY OVER SAID CHILD ON SAID TRIP SHOULD BE UNABLE TO CONTACT EITHER PARENT OF SAID CHILD, THEN I SPECIFICALLY AUTHORIZE ANY MEDICAL ATTENTION WHICH MAY BE DEEMED NECESSARY FOR THE BENEFIT OF SAID CHILD AND I SPECIFICALLY AUTHORIZE THE PERFORMING OF ANY PROCEDURE WHICH SAID ADULT DEEMS ADVISABLE IN ATTEMPTING TO RELIEVE SAID CONDITION.

I agree and do hereby waive and release all claims against Laurel Church of Christ and their representatives, or any other person engaged in the activity in question and agree to hold them harmless from any and all liability relating to said child for any personal injury or illness that may be suffered or any loss of property that may occur to said child arising out of the care and custody of said child during participation in trip.

Adult members having custody over children are, Timothy Conrad, Kelsea Conrad, DeBois Murphy, Janice Murphy, Wayne Dellinger, Michelle Pratt, Annette Young, Stephanie Tam, Tiana Avant, and Jason Tate

TO BE EFFECTIVE FOR THE WINTERFEST YOUTH TRIP FEBRUARY 17-19, 2017 ONLY

Please fill in Home Address: *

Please enter address.

Teen/Child Cell Phone number: * Please enter your phone number.

Child Date of birth: *

Please enter valid date.

Known Allergies (Both environmental and Medical): * Please enter your answer here.

Known Medical Issues: * Please enter your answer here.

Current Medication Taken: (And frequency taken) * Please enter your answer here.

Physician: * Please enter your name.

Physician's Phone number: * Please enter your phone number.

Primary Insurance Carrier: * Please enter your answer here.

Insurance Policy Number: * Please enter your answer here.

Insurance Provider Phone number: * Please enter your phone number.

Emergency Contact 1: * Please enter your name.

Contact 2 - Cell Phone: * Please enter your phone number.

Contact 2 - Home Phone: * Please enter your phone number.

Contact 2 - Work Phone: * Please enter your phone number.

Emergency Contact 2: * Please enter your name.

Contact 2 - Cell Phone: * Please enter your phone number.

Contact 2 - Home Phone: * Please enter your phone number.

Contact 2 - Work Phone: * Please enter your phone number.

Parent Email: (A Copy of this Waiver will be emailed to you) * Please enter your email.

Please Enter Today's Date *

Please enter valid date.

Your signature *

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Your signature *

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Signature date *

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