Life Assembly Liability Waiver and Medical Treatment Authorization Form for MINORS - To be Completed by Parent or Legal Guardian

Minor's Name

First and Last Name

Middle Name

Minor's Phone #

Minor's Address

Minor's Gender at Birth

Minor's Date of Birth

Minor's Medical Information

Minor has Medical Insurance Coverage

Yes No

Medical Insurance Carrier

Policy or Group #

Name of Insured Person

Name of Family Physician

Phone Number/Contact Info of Family Physician

Name of Dentist/Orthodontist

Phone Number/Contact Info of Dentist/Orthodontist

If You Selected Food, Drug, or Environmental Allergies, Please Provide Details Below:

If you Selected

Please List any MEDICATIONS and DOSAGE that Minor is Taking:

Blood Type of Minor - If Known

Are All of Minor's Immunizations Current?

Yes No

Does the Minor have Any DIETARY RESTRICTIONS Beyond Allergies?

Any Other Information that Staff/Leaders Should Know About Minor Participant?

Emergency Contacts

Name

Phone #

Alternate Phone #

Alternate Contact Name

Alternate Contact Phone #

Conduct

Please note the following rules of conduct expected from each minor participant:

-Respect Other Participants, Leaders & Staff
-No Illegal Substances of Any Kind Permitted (Including Alcohol, Any Prescription or Non-Prescription Drugs Not Reported to Leadership, Street Drugs, Tobacco, E-Cigs, et al.)
-No Lighters, Weapons of Any Kind, Fireworks (Including Small Bang Snaps and Sparklers), or Explosives
-Minor's are NOT Permitted to Drive for Any Events
-Respect All Property
-No Entering Sleeping Quarters of the Opposite Sex
-Respect and Comply with Event Schedules
-No Pranks or Practical Joking (Zero Tolerance)
-No Personal Gaming Systems on Group Activities
-No Sexual Misconduct of Any Kind (ZERO TOLERANCE)

Failure to comply with these expectations could result in immediate parent pick-up or other appropriate action-including alerting the authorities in the event of any activity/conduct by minor deemed dangerous of illegal.

My child/the minor in my care has permission to attend any and all Life Assembly sponsored activities as listed in calendars, websites/social media, and/or Life Assembly bulletins or announcements, including but not limited to the following: basketball, rollerskating, games in the park, rollerblading, baseball, kick-ball, games in the building, soccer, broom ball, ice-skating, volleyball, kickball, downhill skiing, snowboarding, hiking, swimming, boating, road tripping, concerts, Bible Studies, hayrides, paintball, amusement park rides, et al.

Yes No

I/We acknowledge that my child/the minor in my care's participation in any and/or all of Life Assembly's programs and activities is voluntary and may require involvement in activities that require travel and physical exertion. Such activities may include, but are not limited to: outing, athletic games, local excursions and meetings. I/We acknowledge that my child/the minor in my care's participation in any Life Assembly activity presents risks, and that my child/the minor in my care may suffer property damage, bodily injury, or death.

Yes No

THEREFORE, in consideration of my child/the minor in my care being allowed to participate in any/all of Life Assembly's programming and/or activities, I/WE AGREE TO THE FOLLOWING:

Misconduct may result in transportation home from any activity at parent/guardian's expense. A student dismissed for a disciplinary reason WILL NOT receive a refund of the activity fee.

I Agree I Disagree

Life Assembly is NOT responsible for the loss or theft of personal belongings.

I Agree I Disagree

I understand and authorize that my child's/the minor in my care's image may be photographed or filmed and used in video presentations, printed publications, and the Internet websites under the name of any of Life Assembly's ministries (LA).

I Agree I Disagree

I hereby take the following action for my child/the minor in my care, myself, my executors, administrators, heir, next of kin, successors and assigns: A) I waive, release, and discharge from any and all claims or liabilities for death or personal injury damages of any ind, which arise out of or related to my child's/minor's participation in Life Assembly's activities, programming, and/or events, the following person, or entities: Life Assembly (LA), it's senior pastor and associate pastors, staff, deacons, employees, volunteers, representatives, subcontractors and agents of any of the above. B) I agree not to sue any of the persons or entities mentioned above for any of the claims or liabilities that I have waived, released or discharged herein except in the case of gross negligence on the part of Life Assembly, Life Assembly's staff or volunteers and: C) I indemnify and hold harmless the person or entities mentioned above from any claims made or liabilities assessed against them as a result of my child's/minor's actions. I hereby assume the risks of my child participating in all Life Assembly programming, events, and activities.

I Agree I Disagree

As the Parent, natural or legal guardian, I hereby execute this document for and on behalf of the minor named herein. I agree to indemnify and hold harmless the person entities mentioned above for any claims or liabilities assessed against them as a result of any insufficiency of my legal capacity or authority to act for and on behalf of the minor in the execution of the waiver and release.

I Agree I Disagree

I hereby authorize any licensed physician, emergency medical technician, hospital or other medical or health care facility to treat the minor named herein for the purpose of attempting to treat or relieve any injury received by said minor. I authorize any such medical provider to perform all procedures deemed medically advisable in attempting to treat or relieve any such injuries. I consent to the administration of anesthesia as deemed advisable. I realize and appreciate that there is a possibility of complications and unforeseen consequences in any medical treatment, and I assume any such risk for and on behalf of myself and said minor. I understand that attempts will be made to contact me in the most expeditious way possible. Permissions is also granted to a Life Assembly representative to provide the needed emergency treatment to the student prior to his/her admission to a medical facility.

I Agree I Disagree

Parent or Guardian's Name

Parent(s) or court appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.

First Name

Middle Name

Last Name

Relationship to Minor

Parent/Guardian Phone #

Parent/Guardian Email Address

By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.

Sign Electronic Signature Consent

Sign Your Name and Date of Signature in the Box Below (This is your Electronic Signature):

Life Assembly Liability Waiver and Medical Treatment Authorization Form for MINORS - To be Completed by Parent or Legal Guardian

Description

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