Harvest Church | Youth Permission Slip
Front Line Youth - Permission Slip
This section to be filled out by authorized persons of Harvest Church:

Medical Release - Authorization for Church Outing - Waiver for Liability (for Minors)

Purpose of Activity:  LASER TAG
Destination:
Clifton Park Bowl, Rt. 9, Clifton Park
Date Leaving: March 16, 2014   Day: Sunday Time:  6:00 PM
Leaving From: Harvest Church, 303 Grooms Road, Clifton Park, NY
Date Returning: March 16, 2014 Day: Sunday Time:  8:00 PM
Pick up at: Harvest Church, 303 Grooms Road, Clifton Park, NY
Supervisor(s): Paulie & Nikki Tebbano

I, ___________________________ of (Street Addres)  __________________________, City of _______________________, County of ________________, State of ____________________, parent/legal guardian of _____________________________, For myself and for my heirs, legal representatives, and assigns do hereby release HARVEST CHURCH of 303 Grooms Road, City of Clifton Park, County of Saratoga, State of New York, their legal representatives, successors and assigns, to never institute any suit or action at law or in equity against HARVEST CHURCH by reason of any claim that I may now have or may hereafter acquire relating to transportation to and from the above event or relating to the administering of first aid by the staff or volunteer nurses from any responsibilities in an emergency or in the administering of medications (e.g. Tylenol or Aspirin) to my child, __________________________. Further, in the event of an emergency where medical personnel is required, I give my permission to the church staff to obtain the services of the necessary medical personnel or licensed physician. In executing this release I expressly reserve any and all rights, causes of action, claims, and demands against any person, firm, or corporation other than HARVEST CHURCH.

I further state that _________________________ is allergic to the following medications/procedures (Please list any allergies to medications or procedures): 

____________________________________________________________
____________________________________________________________

 

____________________________________________________________
                          Releasor - Parent/Legal Guardian Signature


Emergency Contacts: (PLEASE PRINT)
NAME: ______________________________________
PHONE NUMBERS: HOME: _______________ WORK: _____________
CELL:  ___________________________________________________
E-MAIL:  __________________________________________________

NAME: ______________________________________
PHONE NUMBERS: HOME: _______________ WORK: _____________
CELL:  ___________________________________________________
E-MAIL:  __________________________________________________

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