St. Paul Community Church

18200 Dixie Hwy, Homewood, IL 60430

(708) 798-0700

Parental Consent and Liability Form

            In consideration for ____________________ being accepted by St. Paul Community Church for participation in _________________________, we (I) being 21 years or older do for ourself (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 St. Paul Community Church and the directors thereof from any 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 under signed and the child participant that occur while said child is participating in the above-described trip or 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 expenses as a result of participation in recreation and work activity involved herein.

            Further, authorization and permission is hereby given to said church to furnish any necessary transportation, food and lodging for participant.

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

            We (I) authorize an adult, in whose care the minor has been entrusted, to consent to any X-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment, and hospital care, to be rendered to the minor under the general or special supervision and on the advice of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital.  Whether such diagnosis or treatment is rendered at the office of said physician or at said hospital.

            The undersigned shall be liable and agree(s) to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child pursuant to this authorization.

            Should it be necessary for our (my) child to return home due to medical reasons, disciplinary reasons or otherwise, the undersigned shall assume all transportation costs.

            The undersigned does hereby give permission for our (my) child to ride in any vehicle designated by the adult in whose care the minor has been entrusted while attending and participating in the activities sponsored by St. Paul Community Church.

_____________________________              _________________________________

Father                                     Date                  Mother                                           Date

_____________________________              _________________________________

Legal Guardian                     Date                   Participant (if over 21)                  Date

I have read all the foregoing and the rules of conduct for participation and will abide by them and all directions of the trip given by leadership ___________________________.