ADULT AUTHORIZATION AND RELEASE 2017


ADULT AUTHORIZATION AND RELEASE

ADULT NAME:

WARD:

PARTICIPATION IN ACTIVITIES

I agree to participate in activities (the “Activities”) of THE CHURCH OF JESUS CHRIST OF LATTER-DAY SAINTS (the “Church”). Activities include all events sponsored by the Church, including but not limited to, religious services, events of the Boy Scouts of America, young men and women, primary, athletics, conferences, socials, outings, and transportation.

EMERGENCY CONTACT

In case of emergency, please contact the following:

Name(s) & Telephone number(s):

MEDICAL TREATMENT, INSURANCE, INDEMNIFICATION, AND DISCLOSURES

I authorize and approve the providing of medical and dental treatment to me as may become reasonably necessary due to sickness, accident, and/or injury during the course of the Activities. I agree to provide medical insurance coverage for myself during participation in the Activities.

Name of Physician or Medical Group:

Telephone number(s):

Name of Insurance Carrier:

Policy Number:

Medical concerns, allergies, or medication requirements:

I give my permission to receive the following over-the-counter medications that may be dispensed at the discretion and judgment of adult leadership: (Any, None, or Specify)

TERM AND SEVERABILITY

This Authorization and Release shall remain in full force and effect for five years. If any part or portion of this Authorization and Release is unenforceable for any reason, the remainder shall continue in full force and effect. RELEASE OF LIABILITY I HEREBY RELEASE, INDEMNIFY, AND HOLD HARMLESS THE CHURCH, ITS AGENTS, REPRESENTATIVES, VOLUNTEERS, AND HOSTS OF ACTIVITIES, FROM ANY AND ALL LIABILITY, HARM, DAMAGES, COSTS, INCLUDING ATTORNEY FEES, ARISING FROM MY PARTICIPATION IN THE ACTIVITIES. I AGREE NOT TO BRING ANY LEGAL ACTION OR CLAIM FOR DAMAGES AGAINST THE CHURCH, ITS AGENTS, REPRESENTATIVES, VOLUNTEERS, OR HOST BY REASON OF ANY INJURY TO ME, REGARDLESS OF CAUSE OR FAULT, ARISING FROM PARTICIPATION IN THE ACTIVITIES. THE TERMS OF THIS AUTHORIZATION AND RELEASE HAVE BEEN CAREFULLY EXPLAINED TO ME. I UNDERSTAND THE TERMS OF THIS AUTHORIZATION AND RELEASE AND GIVE MY CONSENT TO IT.

Adult Participant’s name:

Date:

Leave this empty:

HB LDS Stake https://hbstake.org
Signature Certificate
Document name: ADULT AUTHORIZATION AND RELEASE 2017
Unique Document ID: 856e422f46764bc8c72dc1236dcefb74f3ccb49c
Timestamp Audit
2017-07-02 07:05:17 PDTADULT AUTHORIZATION AND RELEASE 2017 Uploaded by Trisha Templin - trisha.templin@gmail.com IP 75.83.154.179