Does this child have any disabilities, handicaps, present injuries or limitations, allergies, hemophilia, heart condition, history of respiratory illness or any other significant medical condition? Yes No

If yes, please state condition

If you wish to have your doctor contacted in case of emergency, provide doctors name and phone number:

LIABILITY RELEASE

I hereby release, forever discharge and agree to hold harmless, Emmanuel Church of Greenwood 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 described trip or activity.

Furthermore, I hereby assume all risk of personal injury, sickness, death, damage and expense as a result of participation in recreation, and work activities involved therein.

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

I am the parent/legal guardian of this participant, and hereby grant my permission for my child to participate fully in this event, and hereby give 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.