LEBANON FWB CHURCH
Effingham, SC 29541
Activity Waiver and Release of Liability
and
Health Insurance Information
This form MUST be signed and given to the leader of
this activity before you will be allowed to travel with our group or
participate in this activity.
Participant’s Name: ___________________________________________________
Name and Date of Event: _________________________________________________
I certify that I / or my child, is physically and
mentally capable of participating in the above event. I understand that participation in this event
could result in an unexpected illness or injury, due to accident, forces of
nature, or any other unforeseeable event.
I, my personal representatives, and my heirs, hereby agree to release,
hold harmless, and indemnify Lebanon
Freewill Baptist
Church and its officers from
any and all claims of suit for bodily injury, medical expenses, property
damage, or wrongful participation.
I realize that those who
participate will use private transportation. I agree to abide by the guidelines
provided by the driver of the vehicle in which I travel. I also release the
owner of the vehicle in which I travel from all legal responsibility in the
event of an accident.
I authorize any worker from Lebanon Freewill Baptist
Church to seek treatment
for myself or my child in the event of an injury/ illness while participating
in this church trip or event. My health
insurance information is as follows:
Health Insurance Company: __________________________________________
Insurance ID and Policy Number: __________________________________________
I have read this waiver and understand all of the obligations outlined. By signing this waiver, I give my child permission to participate in the event under these obligations.
Participate or Parent Signature: ___________________________________________
Phone Number: ______________________________________________
Secondary Contact: _____________________________________________
Phone Number: ______________________________________________