First Baptist Church of Mableton > Medical Release Form

Name of Child:____________________________________________________

Address:__________________________________________________________

Child's Date of Birth:_______________________________________________

Any known allergies:_______________________________________________

LIABILITY RELEASE/SPECIAL POWER OF ATTORNEY FORM
FOR THE YEAR 2007

In consideration for being accepted by the First Baptist Church of Mableton for participation in the youth's activities for 2007 we (I), being 21 years of age or older, do for ourselves (myself) (and for and on behalf of my child-participant if said child is not 21 years of age or older) do hereby release, forever discharge and agree to hold harmless the First Baptist Church of Mableton and the directors thereof from any and all liability, claims or demands for personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the child-participant that occur while said child is participating in the above-described activity.

Furthermore, we (I) (and on behalf of our (my) child-participant if under the age of 21 years) hereby assume all risk of personal injury, sickness, death, damage and expense as a result of participation in recreation, transportation, and work activities involved therein.

Further, authorization and permission is hereby given to said church to furnish any necessary transportation, food, or other needs to this participant.

The undersigned further hereby agree to hold harmless and indemnify said church, its directors, employees and agents, for any liability sustained by said church as the result of any negligent, willful or intentional acts of said participant, including expenses incurred attendant thereto.

IF THE PARTICIPANT HAS NOT YET ATTAINED THE AGE OF 21 YEARS:

We (I) are the parent(s) or legal guardian(s) of this participant, and hereby grant our (my) permission for him/her to participate fully in above-described activity, and hereby give our (my) permission to take said participant to a doctor or hospital and hereby authorize medical treatment, including but not in limitation to emergency surgery of medical treatment, and assume the responsibility of all medical bills, if any. Further, should transportation costs be involved, we (I) assume all costs.

First Baptist Church of Mableton may generally do and perform in our (my) name all things necessary in or about the premises as fully and effectually in all respects as I could do if personally present.

This release applies to all activities for the year 2007.

_____________________________________________
Father's Signature / Date

_____________________________________________
Mother's Signature / Date

_____________________________________________
Parent's Phone Number (Day / Night numbers)

_____________________________________________
Legal Guardian's Signature / Date

_____________________________________________
Hospitalization Insurance Company

_____________________________________________
Policy Number

_____________________________________________
Emergency Contact / Phone Number

Witness thereof; I have hereunto set my hand and seal,
Sworn to and subscribed before me this _________day of _________,20___.

____________________________________________
Notary Public