7/30/2019 Brooklyn Lights Release Form

1/1

Renaissance Medical and Liability ReleaseBrooklyn Lights 12.16.12

STUDENTSNAME: BIRTHDATE: AGE:

ADDRESS: CITY: ZIP:

EMAIL: GRADE MALE FEMALE

Parents'orGuardians'Names:

HOME PHONE: ( ) WORKPHONE: ( ) CELL:( )

Loca lEmergencyContact(inca s eparent(s)areoutoftown):

Name: PHONE: ( )

LIABILITYRELEASEEvery activity sponsored by thischurch is carefullyplannedand adequately supervised by mature adults.However, even with thebest ofplanningand

precaution, unforeseen eventscanoccur. Bysigningthisform,youagreetoassumeandacceptallrisksandhazardsinherent in church-relatedsocialansport activitiesincluding transportation toand from activities.You also agree thatyou willnot hold Renaissance Church or its employees orvoluntee

assistantsliablefor damages,lossesorinjuriestothepersonnamedonthisform.Youunderstandthatthisformandyoursignatureareforbothmedicaland

liabilityrelease.

MINOR'S LIABILITYRELEASE

Igivepermissionformychild, , toparticipate in allactivitiesaspartoftheministyofRenaissance Church

ofSummit,NJ.Asparent orlegalguardianofsaidminor, Iacceptfullresponsibilityformychild'sparticipation in Renaissance Churchactivitiesincluding

transportation toandfromanylocationin connectionwithRenaissance Churchevents.Iwillassumefullresponsibilityforanymedicalcostsincurred in thevent ofanaccident orotherincidentrequiringmedicaltreatment.IreleaseRenaissance Churchfromanyliability. Intheevent ofanemergencyin whichm

childis in needofimmediatehospitilization,medicalattention orsurgery, andafterreasonableeffortshavebeenmadetocontactmeormyspouseandwe

cannotbelocatedforthepurpose ofconsentingthereto,consentfortheemergencyattention maybegiventoanypersonstandinglocoparentistomychild

isunderstoodthatmychildwillobeyallregulationsandfollowinstructionsoftheleaders.Iagreetopayanyexpensesincludingthecostofmyson/daughtebeingsenthomeifdisciplineis deemednecessary.

TheaboveLiabilityandMedicalReleasecoversanyandallactivitiessponsored byorassociatedwithRenaissance Church.

INSURANCE:Ourchurch'sinsuranceisonlysecondaryinsurance.Ifyouhavemedical insurance,yourcarrierwillbebilledformedicalcharge s in thecaseofillnessor

injurywhileparticipating in activitiesoronthechurch premises.

Parent/GuardianSignature: Date:

PrintName:

Renaissance Church 2 Kent Place Blvd Summit ,NJ 07901 973.921.2945