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: Fall Advance 2014
Destination: Sacandaga Bible Conference, Broadalbin, NY
Date Leaving:  September 26, 2014  Day: Friday   Time: 3:00 PM
Leaving From: Harvest Church, 303 Grooms Road, Clifton Park, NY 
Date Returning: September 27, 2014   Day: Saturday  Time: 11:00 PM
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:  ____________________________
E-MAIL:  ____________________________
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