Transportation and Medical Liability

I, the undersigned parent or legal guardian of the child names below, do hereby grant my permission and consent for the 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 further agree not to hold Kingdom Empowerment Christian Church Inc., any of it’s paid staff or volunteers responsible for any accident that may occur on the way to, from, or during an event. I indemnify, defend, and hold harmless Kingdom Empowerment Christian Church Inc. for all claims made and liabilities assessed against them as a result of any activity or event. I release Kingdom Empowerment Christian Church Inc. it's paid staff or volunteers and all medical providers from liability in acting on my behalf in this regard and rendering such medical treatment. I assume the risk and financial responsibility for any injury resulting from an event or activity.

By signing below, I am acknowledging that I have read through and understand the above statements.

* 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