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: Feed the Children
Destination: JC Club, Albany, NY
Date Leaving: July 12, 19, 26, August 2, 16, 23, 2018 Day: Thurs. Time: 8:00am
Leaving From: Harvest Church, 303 Grooms Road, Clifton Park, NY
Date Returning: July 12, 19, 26, August 2, 16, 23, 2018 Day: Thurs. Time: 3:00pm
Pick up at: Harvest Church, 303 Grooms Road, Clifton Park, NY
Supervisor(s): Paulie & Nikki Tebbano

I, ____________________________ of (Street Address) _____________________________________, 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:  ______________________________

Harvest Church Inc.
Harvest Church, 303 Grooms Road, Clifton Park, New York 12065
518-371-2997 or paulie@soldoutforjesus.com

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