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NAME:_______________________________________      DATE:______________             

            Name of Minor                                                                                                                         Today's Date

 In Consideration for being accepted by ________________California, which shall be referred as ___________, for participation in: (Please circle one) 

A: _______________________, meets every Wednesdays, during the school year from 7pm to 9pm, and during the summer every other week.  

B: _______________________, meets _______________, during the school year from __________. 

C: _______________________, meets _______________, during the school year from __________. 

As a parent/ Guardian of above minor youth and participant in the above program, I do hear by release, forever discharge and agree to hold harmless __________, and the directors/ pastors/ volunteers thereof, from any and all liability, claims, or demands for personal injury, sickness or death, as well as property damage and expenses. 

This release covers transportation provided by __________ and its representatives who are properly licensed to drive in the state of California: And meetings on the ___________ campus site or any other site during programs and activities: And refreshments, purchased or homemade that will be served at above program: And Consent for emergency Medical or Dental Treatment, including examination, diagnosis, treatment, anesthetic, and surgical treatment, the undersigned agrees to pay for all costs and expenses. Please write on back page any allergies, or medical problems, or medications.  

This Liability Release Form will remain in effect as long as the named minor child/ youth is a participant in the program, or the child/youth reaches adulthood at 18.  

Medical Information

Insurance Co.___________________________    Home Phone___________________ 

Name of Insured_________________________    Cell Phone_____________________ 

Policy #________________________________    Work Phone___________________

Physician_______________________________           

 I have read the above and understand the information: 

___________________________________        _______________________        

   Signature of parent/guardian                                         Print your name 

Date______________________                Accepted by__________________________

Today's date                                                      Youth Pastor/ Church Secretary

(Make sure you check with your churches insurance company and denominational resources first)