Liability Release



Consent and Release of Liability For I.M.P.A.C.T. Sponsored Youth Events


Sponsoring Church or Organization:  

Oak Grove Baptist Church, Grafton WV


I, the undersigned parent (s) or guardian (s) do hereby consent for my child, as herein named, and who is of the age as disclosed herein, to participate in the activity or activities in which i select below.  I certify that the child able, willing, and permitted to participate in any and all of the activities selected herein.  If my child has medical conditions which may be relevant to a physician in the event of an emergency, i have listed them herein.  If i cannot be reached within a reasonable period of time, as determined by church officials, i hereby authorize the church or its agent / representative acting in its behalf to make emergency medical decisions for my child.  If there are any activities that i do not want my child to be involved in, i have listed them in the space provided below.  


I UNDERSTAND AND HEREBY AGREE TO ASSUME ALL OF THE RISKS WHICH MAY BE ENCOUNTERED ON SAID ACTIVITIES, INCLUDING ACTIVITIES PRELIMINARY AND SUBSEQUENT THERETO.  I do for myself and for my child, heirs and assigns, hereby irrevocably and unconditionally release, acquit, and forever discharge any and all liability, actions, causes of actions, claims, expenses, obligations and damages, of any nature whatsoever, which i now have or which may arise in the future, in connection with my child's participation in the described activity or in any other associated activities including, but not limited to, any injury to my child or property even injury resulting in death.


I expressly agree that this release, waiver, and indemnity agreement is intended to be broad and inclusive as permitted by the law of the State of WV and that if any portion hereof is held invalid, it is agreed, that the balance shall, notwithstanding, continue in full legal force and effect.  This release contains the entire agreement between the parties hereto.


I further state that I HAVE CAREFULLY READ AND UNDERSTAND  THE FOREGOING RELEASE AND KNOW THE CONTENTS THEREOF AND SIGN THIS RELEASE AS MY OWN FREE ACT.  I UNDERSTAND THAT THIS IS A LEGALLY BINDING AGREEMENT.


Name of Student:
Age of Student:
Medical Conditions to
be aware of:

Physical Restrictions:
Current Medications & any instructions:
Date of Last Tetanus:
Emergency Contact:
Name & Number

  
This Consent and Release is intended to cover the following IMPACT Sponsored Events:
 08.17.18 Lock-in - Grafton Social Center 118 St John St, Grafton  
   
    
SIGNED & AGREED  
Parent/Legal Guardian Signature:
 
Date: