Microsoft word - liability form 2012-2013

PERMISSION, RELEASE OF LIABILITY AND MEDICAL AUTHORIZATION
The period covered by this Permission and Medical Authorization is from September 1, 2012 through August 31, 2013 Part I or II Must Be Completed
Part I - To Grant Consent
I, ________________________________________, being (Mother) (Father) or (Person having legal
custody) of ___________________________________________, do hereby give permission for my son
or daughter to participate in youth activities offered by Church of the Nativity, Raleigh, and in
connection therewith do hereby authorize said church to transport my son or daughter either by vehicles
owned by the church or in private vehicles furnished by authorized adult volunteers or employees of the
church to various activities throughout the state of North Carolina and contiguous states.
As parent (or legal guardian) of the above stated youth, I attest that he or she is in good health and that I
know of no physical, mental, or emotional reason that would prohibit my son or daughter from attending
youth group activities. I understand that every measure and precaution has been taken to assure the
good health and safety of each participant and therefore I waive any liability of Church of the Nativity or
staff or volunteers representing it for personal injury or death while attending the group’s activities.
I hereby give consent for the following medical care providers and local hospital to be called:
Doctor: __________________________________________ Phone: ___________________________
Dentist: __________________________________________ Phone: ___________________________
Medical Specialist: _________________________________ Phone: ___________________________
Local Hospital: ____________________________________ Phone: ___________________________
Medical Insurance Company: _________________________ Policy Number: ___________________
In the event that reasonable attempts to contact me have been unsuccessful, I hereby give my consent for
(1) the administration of any treatment deemed necessary by the above-named doctor, or, in the event
the designated preferred practitioner is not available, by another licensed physician or dentist; and (2)
the transfer of the child to any hospital reasonably accessible.
This authorization does not cover major surgery unless the medical opinions of two other licensed
physicians or dentists, concurring in the necessity for such surgery, are obtained prior to the
performance of such surgery.

Facts concerning my child’s medical history including allergies, medications being taken, current
medical treatments and any physical impairment to which a physician should be alerted are:
____________________________________________________________________________________
____________________________________________________________________________________
Please circle any of the following over the counter medications that the youth should not be given:
Acetaminophen Decongestants Tylenol Antacid Imodium antidiarrheal Kaopectate
Pepto-Bismol Aspirin Ibuprofen Hydrocortisone cream Antihistamines Antiseptic cream
Other (specify)________
Signature of Parent/Guardian: ________________________________________ Date: ____________
Parent’s Phone: _______________________________ Alternate Phone: _______________________
Address: ___________________________________________________________________________
Part II - Refusal to Consent
I do NOT give consent for emergency medical treatment of my child. In the event of illness or injury
requiring emergency treatment, I wish the Church of the Nativity staff members and/or volunteers to
take the following action:
____________________________________________________________________________________
____________________________________________________________________________________
___________________________________________________________________________________
Signature of Parent/Guardian __________________________________________ Date: ____________
Parent’s Phone: ________________________________ Alternate Phone: ______________________
Address: ___________________________________________________________________________

State of North Carolina
County of Wake

Before me, the undersigned notary public, personally appeared ________________________________,
who, after being duly sworn, deposes and says that he or she has read the foregoing Permission and
Medical Authorization, Release of Liability, and medical information sheet and that the matters stated
herein are true and correct to the best of his or her knowledge and belief.
Signature of person having legal custody: _________________________________________________
Sworn to and subscribed before me this _________________ day of______________________20___
Notary Public ______________________________________________________
My commission expires: _____________________________________________

Source: http://nativityonline.org/wp-content/uploads/2013/01/Liability-form-2012-2013.pdf