Church Calendar

                                                 Department Outing

Permission, Waiver and Release

I, the parent/guardian of                                                                           , do hereby give permission for him/her to attend the Liberty Hill Baptist Church                                                                   Department outing. I, do hereby agree that by signing this form, I release and discharge Liberty Hill Baptist Church and all persons connected with Liberty Hill Baptist Church from any liability or medical claim my child may incur due to any accident or injury while my child is with the Liberty Hill Baptist Church                                                     Department outing. Further, I agree to give all chaperones in charge on the day my child is in attendance permission to grant any and all medical treatment necessary to treat my child for any accident, illness or injury in my absence.

Date:                                                                                                               

Trip Destination:                                                                                            

MEDICAL CONDITIONS WE SHOULD BE AWARE OF (ex: asthma, diabetes, etc.).

EMERGENCY PHONE NUMBERS- PLEASE GIVE THE NAME OF THE PERSON AND THE RELATION TO THE PARTICIPANT:

SIGNATURE OF PARENT/GUARDIAN:

NOTARY SIGNATURE & SEAL IF REQUIRED                                                                                                       

THIS SIGNED RELEASE IS REQUIRED TO PARTICIPATE (NO EXCEPTIONS)

2957 Mt. Carmel Road * Hampton, GA 30228 * 770-946-3238