North Central Baptist Association

Mission Trip - Minor

 

      RELEASE, HOLD HARMLESS, AND INDEMNITY AND MEDICAL AUTHORIZATION FOR MINOR  

Release, Hold Harmless and Indemnity:

I, the undersigned, as parent or legal court-appointed guardian of _____________________, a minor under the age of eighteen (18), (“minor”), with full authority to act on behalf of minor, do hereby agree and give my consent to the minor participating in the events, programs, and activities (“activities”) during the North Central Baptist Association (“NCBA”) mission trip to _________________ (“mission trip”).  I, on my own behalf and on behalf of minor, acknowledge that participating in the activities involve possible risks, and that injuries, death or other harm (including damage to minor’s property) could occur to minor (“injuries”).  By allowing minor to participate in the activities, I, on my own behalf and on behalf of minor, hereby assume full responsibility for the risk of injuries, whether caused by negligence or otherwise.  I, on my own behalf and on behalf of my heirs, successors, assigns, executors and administrators, hereby RELEASE AND HOLD HARMLESS AND AGREE TO INDEMNIFY North Central Baptist Association of North Central Louisiana and its staff, volunteer leaders, employees, trustees, Executive Board members, churches, ministry and church leadership (“NCBA”) from and against any and all liability, claims, damages, causes of action, loss, costs and expenses (including, without limitation, attorney fees) for injuries arising out of or connected with the mission trip, including traveling to and from the location(s) of the mission trip.

 

Medical Consent and Authorization:

 

If, while participating in the mission trip, minor requires emergency medical treatment, I hereby give my consent for any emergency medical care to be rendered to minor as may be deemed necessary by any duly licensed physician or dentist.  I hereby give my permission to NCBA to obtain the emergency medical treatment at any hospital, clinic or other health care provider as may be deemed appropriate.  In these circumstances, I hereby request and authorize any duly licensed physicians, dentists and staff, or other licensed technicians or nurses, to perform any diagnostic procedures, treatment procedures, operative procedures and x-ray treatment as may be necessary, including but not limited to medical transport, hospital tests, injections, anesthesia, surgery and administration of prescription drugs.  I agree to the release of any records necessary for treatment, referral billing, or insurance purposes from any Medical Contracts provided by NCBA.  I agree to assume full responsibility for medical expenses incurred as a result of such emergency medical treatment.

 

Parent/Guardian Signature:  

                                   

_____________________________________           

Signature        

                                                      

_____________________________________           

Printed Name    

                                                     

Date:  ______________________________         

 

          WITHOUT THIS FORM WITH MINOR AND SIGNED, MINOR WILL NOT BE ALLOWED TO PARTICIPATE

 

               A copy of the signed form shall be filed with the Associational office prior to trip departure.

 

 

 

 

MISSION TRIP RELEASE FORM – MINOR

 

Participant’s Name:  _________________________________________________    Date: _________________

Address: ______________________________________________________________________________________

E-Mail (parent): ___________________________________  Phone: ____________________

E-Mail (minor): ____________________________________ Phone: ____________________  

Age: _________        Grade: ______________         Birthdate: ________________________

Insurance Carrier: __________________________________________  Policy #: ________________________

Physician’s Name: __________________________________________  Phone:  _________________________

 

Allergies: _____________________________________________________________________________________

Chronic Illnesses:  ____________________________________________________________________________

Medication Currently Taking: _________________________________________________________________

Physical Limitations (please list):  _____________________________________________________________

Blood type: __________________      Is minor subject to motion sickness? _____ yes  ____ no

Is minor allergic to any medications (please list): _____________________________________________

 

PHOTO AND VIDEO PERMISSION

My permission is granted for NCBA to videotape or photograph my child or young person during mission trip events and normal activities.  I understand these photos may be used in report and/or promotional materials.

Signature of Parent/Guardian: __________________________________________________

 

 

Emergency Contact Information: 

Name: ________________________________________________________________

Home Phone: _____________________ Cell Phone: _____________________ Work Phone: ____________________

Other person(s) to contact if above name is not available: 

Name:   ___________________________________       Phone: __________________________

               ___________________________________                    __________________________

               ___________________________________                    __________________________