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Willow Glen Bible Church
Permission - Liability Release Form
Student First Name
Student Last Name
Address 1
Address 2
City
State
Zip Code
Student's Phone #
Student Email
Student Birthdate
First Parent's Name
Second Parent's Name (if applicable)
Parents' Phone Numbers
Known Allergies
Date of Last Tetnus Shot
Existing Medical Insurance Co.
Medical ID #
Name of Primary Care Physician
Physician Phone #
Any other known health issues or limitations we should be aware of?
I permit my child, (name)
to participate in (name of activity)
on (date)
with Willow Glen Bible Church. I understand and fully accept that accidents and injuries are possible. I hereby release and hold harmless Willow Glen Bible Church, its officers and employees, and designated volunteer group leaders and chaperones, from all liability and from all actions or claims that I or my child now or hereafter have for any damage injury to my child, or to any person or property, resulting from negligence or other actions of any employees or agents in connection with my child’s participation in this activity. In case of medical emergency, I hereby give permission to the group leader to order medical treatment, including needed tests and x-rays, for my child. Of course, I understand that an attempt will be made to reach me by telephone immediately after any injury and when the diagnosis is completed.
I give my permission
Submit
