Transportation and Medical Liability

I, the undersigned parent or legal guardian of the child names below, do hereby grant my permission and consent for said child to attend and participate in the events and activities of Kingdom Empowerment Christian Church Inc. both on and off church grounds, including the necessary transportation to and from these events and activities.

I hereby give permission for my child/children to be transported in a motor vehicle or other modes of transportation as necessary, to include a private owned vehicle, if and when necessary. I recognize that by participating in this activity, as with any activity involving transportation, my child/children may risk personal injury or permanent loss and I have full knowledge and consent of said risk and I assume any expenses that may be incurred in the event of an accident, illness or other incapacitation.

I, my child, my executors and assigns further agree to release and forever discharge Kingdom Empowerment Christian Church Inc., any of it’s staff (paid or volunteers) from any claims and/or accident that may occur on the way to, from, or during an event. I indemnify, defend, and hold harmless Kingdom Empowerment Christian Church Inc and it's staff from all claims made and liabilities assessed against them as a result of any activity or event. I release Kingdom Empowerment Christian Church Inc.and it's staff and all medical providers from liability in acting on my behalf in this regard, rendering such medical treatment. I assume the risk, financial responsibility and hereby give consent for medical treatment if any injury should occur from an event or activity.

By signing below, I am acknowledging that I have read this entire waiver and permission form and I fully understand it and agree to be legally bound by its term.

* Indicates required field

YOUTH'S NAME *

First

Last

YOUTH'S Phone Number *

Date of Birth (mm/dd/year) *

Address *

Line 1

Line 2

City

State

Zip Code

Country

IN CASE OF EMERGENCY, PLEASE CONTACT *

First

Last

POC CELL NUMBER *

RELATIONSHIP TO YOUTH *

EMERGENCY POC #2 *

First

Last

POC #2 CELL NUMBER *

RELATIONSHIP TO YOUTH *

Emergency Point of Contact must be over the age of 18 and have the permission of Parents/Guardians

SIGNATURE OF PARENT/GUARDIAN *

DATE (MM/DD/YEAR) *

Phone Number *

Submit

TRANSPORTATION