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HOLD HARMLESS, MEDICAL TREATMENT, MEDIA RELEASE, and EVENT PERMISSION FORM To: PARENT/LEGAL GUARDIAN 2012


Events: Official Ministry Events and Activities of Liberty Lighthouse Church of God Events Location(s): Daytona Beach


This form must be accompanied by the River of Life Health Form.


Minor’s Last Name _________________________________ Minor’s First Name / Nickname _____________________________________ Minor’s Birthday __________________________________ Minor’s Home Phone # __________________________________Gender M / F Minor’s Address ______________________________________________ City ______________________ State ______ Zip ___________ Person(s) to contact in case of an emergency: (complete all blanks that apply) Mom/Guardian: ___________________________________________ Phone: _____________________Work Phone: _________________ Dad/Guardian: ____________________________________________ Phone: _____________________ Work Phone: _________________ Complete Address: _________________________________________________________________________________________________ Cell/Pager: ______________________________ Other: ___________________________________________________________________


Who is authorized to pick up and leave with this minor? List all who apply: ____________________________________________________


I, ________________________________, agree to these statements and conditions for _______________________________ (“my minor”) (Please print name of parent / legal guardian)


(Please print name of minor)


as this agreement pertains to my minor’s participation with Liberty Lighthouse Church of God, 1021 Liberty Ave. Mt. Dora, FL activities/events for the entire Period of Consent. All copies, facsimiles, and reproductions of this document shall be as valid as the original.


Section 1. HOLD HARMLESS I hereby consent to participation, by my minor listed above, in the activities/events of The Church. I do hereby release The Church, its directors, employees, land owners, and agents from any and all liability, claims, or demands for personal injury, sickness, or death, as well as property and expenses, of any nature whatsoever which may be incurred by me or my minor while my minor is participating in the above-described activity including recreation, work activities, and transportation. I further hereby agree to hold harmless and indemnify The Church, its directors, employees, land owners, and agents for any liability sustained by said acts of my minor, including expenses incurred attendant thereto.


Section 2. EMERGENCY MEDICAL TREATMENT PERMISSION I understand that on rare occasions an emergency requiring hospitalization, surgery, and/or other medical treatment can develop. I understand that the designated supervisor of The Church events/activities will attempt to contact me prior to exercising this emergency treatment consent. I understand that this emergency treatment consent is important to prevent delays if an emergency does occur and The Church is unable to contact me. In the event of injury or illness to my minor, I hereby authorize a designated activity supervisor of The Church to give consent to whatsoever medical treatment the representative deems necessary, including the administration of an anesthetic and surgery, and do here release and hold harmless The Church, its directors, employees, land owners, and agents from any acts of malfeasance, and/or failure to act on the part of those chosen to administer medical care on behalf of my minor.


Section 3. MEDIA RELEASE I understand that The Church collects, records, publishes, posts, transmits, and displays audio/visual “media” (images, recordings, videos, and other media) to further its ministry purposes. With this understanding, I give permission for media of my minor above to be collected, recorded, published, posted, and displayed to further the ministry purposes of The Church. I hereby voluntarily release and hold harmless The Church, its directors, employees, land owners, and agents acting officially or otherwise, from all manner of suits, actions, claims, demands, and liabilities which may arise from my minor’s media participation. This release applies to all media displayed publicly, on the church web site, via emails, or in any way made available for viewing or listening by The Church or general public. I understand that all media remains the property of The Church, and waive all rights to original media, copies of media, royalties, entitlements, payments, or any other compensation or quid pro benefits which might arise from The Church’s acquisition, storage, display, publication, posting, or distribution of media of my minor. I understand that this document constitutes a full and complete waiver of all possible claims of any nature whatsoever, including claims of negligence, personal injury or property loss, or damage, arising out of my minor’s media participation.


Section 4. EVENT PERMISSION I hereby consent to participation, by my minor listed above, in the activities/events of The Church. I understand that events may take place at The Church or any other location inside of Okaloosa, Escambia, Santa Rosa and Walton Counties, Florida.


Signature: _________________________________________________________________________ Date: ____________________________ (Parent of Legal Guardian, please sign here)


(Date of Signature)


Parent / Guardian Comments: __________________________________________________________________________________________ STATE OF FLORIDA, COUNTY OF OKALOOSA


Subscribed and sworn before me this _____ day of __________________ , 2009, by ______________________________________________ (Name of Parent or Legal Guardian)


(Seal)


__________________________________ Notary Public O


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