WMUMC Liability Release and Medical Information
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  • Student Information

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  • Parent or Guardian Information

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  • Emergency Contact

    In case of emergency, and the parent/guardian cannot be reached please contact the following person.
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  • Insurance and Doctor Information

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  • Medical History and Additional Information

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  • Liability Release

    In consideration for being accepted by WILLIAMS MEMORIAL UNITED METHODIST CHURCH for participation in WILLIAMS MEMORIAL STUDENT MINISTRY ACTIVITIES as 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 WILLIAMS MEMORIAL UNITED METHODIST CHURCH 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 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 expense as a result of participation in recreation and work activities involved therein.

    Further, authorization and permission is hereby given to said church to furnish any necessary transportation, food and lodging for 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 the negligent, willful or intentional acts of said participant, including expenses incurred attendant thereto. (If the participant has not attained the age of 21 years):

    Further, authorization and permission is hereby given by the undersigned to said church to photograph participant and use the photographs and likenesses of participant in any manner or media that it chooses, including but not limited to newsletters, websites, social media or advertising.
  • By checking this box I agree to the liability release terms as stated above.
  • Medical Release

    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 said trip, 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 or medical treatment, and assume the responsibility of all medical bills, if any. Further, should it be necessary for the participant to return home due to medical reasons, disciplinary action or otherwise, we (I) hereby assume responsibility for all transportation costs.
  • By checking this box I agree to the liability release terms as stated above.
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