EmailMe Form - Medical and Liability Release

We (the parents/guardians) believe the necessary precautions and plans for the care and supervision of our child will be taken during any trip sponsored by Genesis CDC. So, on behalf of the said student we (I) hereby release, forever discharge, and agree to hold harmless Genesis Community Development Corporation (Genesis), Board of Directors, Executive Director, staff, chaperones, and supervisor of this trip, from any and all liability, claims or demands for personal injury, sickness, COVID 19, etc. including transportation to and from the activity. Further, authorization and permission is herby given to Genesis and its agents to furnish any necessary transportation, food and lodging. Furthermore, we (I) hereby assume all risk of personal injury, sickness, death, damage and expense as a result of participation in recreation and excursion activities involved therein.

I Agree *

Yes

We (the parents/guardians) believe the necessary precautions and plans for the care and supervision of our child will be taken during any trip sponsored by Genesis CDC. So, on behalf of the said student we (I) hereby release, forever discharge, and agree to hold harmless Genesis Community Development Corporation (Genesis), Board of Directors, Executive Director, staff, chaperones, and supervisor of this trip, from any and all liability, claims or demands for personal injury, sickness, COVID 19, etc. including transportation to and from the activity. Further, authorization and permission is herby given to Genesis and its agents to furnish any necessary transportation, food and lodging. Furthermore, we (I) hereby assume all risk of personal injury, sickness, death, damage and expense as a result of participation in recreation and excursion activities involved therein.

I Agree *

Yes

List any relevant allergies, illnesses, condition, or information

Liability Release

Every activity sponsored by this organization, Genesis CDC, is carefully planned and adequately supervised by mature adults. However, even with the best of planning and precaution, unforeseen events can occur. By signing this form, the parent or guardian agrees to assume and accept all risks and hazards inherent in all
tour activities. They also agree not to hold this organization, its employees or volunteer assistants liable for damages, losses or injuries to the person or property undersigned. Either parent, if both parents have legal custody, or the parent or person having legal custody or the legal guardian, of a minor may authorize in writing any adult person into whose care the minor had been entrusted to consent to any X-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital care to be rendered to said minor under the general or special supervision and upon the advice of a physician and surgeon licensed under the provisions of the Medicine Practice Act or to consent to a X-ray examination, anesthetic, dental or surgical diagnosis or treatment and hospital care to be rendered to said minor by a dentist licensed under the provisions of the Dental Practice Act. (California Civil Code Section 25.8: Added Stats. 1965, c.1524, p. 3616, s 1.).

The parents or guardians understand that they are signing for the minor listed on this form and the signature is for both a medical and liability release. This authorization shall remain effective until terminated in writing and delivered to the Program Manager or designee of Genesis Community Development Corporation.

Student Information

Student Name *
First Last

Student Age *

Student Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Parent/Guardian Emergency Contact Information

Parent/Guardian Emergency Contact Name *
First Last

Parent/Guardian Emergency Contact Email *

Parent/Guardian Emergency Contact Home Phone *
### - ### - ####

Parent/Guardian Emergency Contact Cell Phone *
### - ### - ####

Emergency Contact Information

Secondary Emergency Contact Name *
First Last

Secondary Emergency Contact Phone *
### - ### - ####

Secondary Emergency Contact Email *

Insurance Company Information

Insurance Company Name *

Insurance Company Phone *
### - ### - ####

Insurance Company Address *

Street Address Address Line 2 City State / Province / Region Postal / Zip Code Country / Region

Physician Name *
First Last

Physician Phone *
### - ### - ####

Parents/Guardian Signatures (Must be signed by both parents unless parents are divorced or separated)

Parent/Guardian Name *
First Last

Date Time *
MM / DD / YYYY

Parent/Guardian Signature *
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Parent/Guardian Name *
First Last

Date Time
MM / DD / YYYY

Parent/Guardian Signature
Clear
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