Mt. Moriah Lutheran Church Event Permission Slip, Liability Release, Photo Release and Medical Form
Child’s Name Birth Date
(One form per child)
How did you hear about this event?
Permission and Liability Release
As legal guardian I give my permission for my child to attend events sponsored by Mt. Moriah Lutheran Church. I understand in the event of an emergency, or if any medical or surgical care becomes necessary for my child every attempt will be made to contact me. If I am unavailable, I grant those leadingthe event permission to authorize medical attention as recommended by a licensed physician or emergency medical provider. I understand that I have a duty to provide primary accident and medical insurance for my child and I declare that my child is covered by primary accident and medical insurance. I agree to bear all medical expenses that my child may incur arising out of or related to the event. Mt. Moriah Lutheran Church is not responsible for any medical insurance or medical costs for individuals attending sponsored events.
I release and discharge Mt. Moriah Lutheran Church, and its directors, trustees, officers, employees, volunteers, and representatives involved in the event (or otherwise), on behalf of myself, my family members, and my child, from any liability, claims or damages suffered by me, my family members or my child arising out of or related to (i) the event, whether caused by ordinary negligence or otherwise, and/or (ii) rights of publicity, invasion of privacy, defamation and all other causes of action arising out of the production, editing, distribution, broadcast, exhibition and other exploitation of the Property (as that term is defined below). Finally, I, on behalf of myself, my family members, and my child, voluntarily and knowingly assume all risks associated with the event.
Contact Information
Parent/Legal Guardian Names:
(Print Name)
Address:City:Zip:
Home Phone:Cell Phone:
Email:
Physician’s Name:Office Phone:
Medical Insurance Company:Policy Number:
Medical Information:
Date of last Tetanus shot:
Allergies (including drug and food allergies):
Regular Medications and instructions for use:
Remarks and special instructions to aid child (i.e. if baby, feeding schedule and how much):
Photo Release: We often take photographs, video recordings and audio recordings of participants at our events (the “Property”) for use in operational, administrative, promotional, advertising and marketing materials and for sharing our event highlights with church members, such as event flyers, newsletters, the church website and Facebook page, brochures, and bulletin board and slideshow presentations. I hereby grant Mt. Moriah Lutheran Church the irrevocable and perpetual right and license to use the Property for the above-listed (and related) purposes. I further hereby grant to Mt. Moriah Lutheran Church the irrevocable and perpetual right to edit, alter and create derivative works of the Property as Mt. Moriah Lutheran Church may choose in its sole discretion, and to reproduce the Property in any format or media.
Parent/Legal Guardian Signature:Date:
6/30/2017