CBC Church Trip Release Form – Adults

Church Trip Release Form - Adults

  • Please enter a value between 10 and 60.
  • Medical Information

  • By clicking yes, you grant permission for Crestwood Baptist Church to videotape or photograph your child or young person during the church event or normal activities. You understand these photos may be used as church promotional materials.
  • Emergency Contact Information

  • RELEASE, HOLD HARMLESS AND INDEMNITY AND MEDICAL AUTHORIZATION

  • I, the undersigned, acknowledge that participating in the CBC Mission Trip to ________________ (the “Mission Trip”) involves certain risks and that injury, death, or other harm (including damage to property) could occur to me (“Injuries”). By participating in the Mission Trip, I hereby assume full responsibility for the risk of Injuries, whether caused by negligence or otherwise. I, on my own behalf and on behalf of my heirs, successors, assigns, executors and administrators, hereby RELEASE AND HOLD HARMLESS AND AGREE TO INDEMNIFY Crestwood Baptist Church of Crestwood, Kentucky, Inc. and its staff, volunteer leaders, members, employees, deacons, council members, Ministry and Church Leadership (hereinafter collectively referred to as “CBC”) from and against any and all liability, claims, damages, causes of action, loss, costs and expenses (including, without limitation, attorneys fees) for Injuries arising out of or connected with the Mission Trip, including traveling to and from the location(s) of the Mission Trip.
  • MEDICAL CONSENT AND AUTHORIZATION

    If, while participating in the Mission Trip, I require emergency medical treatment, I hereby give my consent for any emergency medical care to be rendered as may be deemed necessary by any duly licensed physician or dentist. I hereby give my permission to CBC to obtain the emergency medical treatment at any hospital, clinic or other health care provider as may be deemed appropriate. In these circumstances, I hereby request and authorize any duly licensed physicians, dentists and staff, or other licensed technicians or nurses, to perform any diagnostic procedures, treatment procedures, operative procedures and x-ray treatment as may be necessary, including but not limited to medical transport, hospital tests, injections, anesthesia, surgery and administration of prescription drugs. I agree to the release of any records necessary for treatment, referral, billing, or insurance purposes from any Medical Contacts provided to CBC. I agree to assume and pay for all costs of such emergency medical treatment.
  • Signature will be required.