New Community Church
Medical/Liability Release Form
Kennywood Park Trip
July 8, 2009
I understand that if in the event that medical intervention is needed, every attempt will be made to contact immediately the persons listed on this form. In the event I cannot be reached in an emergency during the activity date shown on this form, I hereby give permission to the physician or dentist selected by the activity leader to hospitalize, to secure medical treatment, and/or to order an injection, anesthesia, or surgery for my child as deemed necessary.
I understand that my insurance coverage will be used as primary coverage in the event medical intervention is needed. Coverage by New Community Church’s insurance policy will be used as a backup for what my family’s insurance does not cover.
I understand all reasonable safety precautions will be taken at all times by the Kennywood Park Trip Staff, New Community Church and its field staff during the event and activities. I understand the possibility of unforeseen hazards and know of the inherent possibility of risk. I agree not to hold New Community Church, its leaders, employees, and volunteer field staff liable for damages, losses, diseases, or injuries incurred by the subject of this form.
NAME___________________________________________GRADE____________
STREET__________________________CITY_______________ZIP____________
PARENT’S SIGNATURE____________________________DATE______________
Any questions or further information contact (Jaida or Christine at the NCC office at 724-935-0909).