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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.
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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: __________________________
___________________________________ __________________________
___________________________________ __________________________