Youth Emergency release

Highland Community Church

3130 McMillan Rd.   Abbotsford BC   V2S 6A8



Youth Ministries
Emergency Release


When we plan an event for our students, not only do we want to plan a fun, exciting event, but we hold the health and safety of the participants as our primary concern. Part of that is to ensure that you know what your son/daughter is doing, and if in the unlikely event we need to contact you in an emergency, we have that information at our fingertips.


Please note: this information will be made available to Student Ministry leaders or Highland Community Church elders or staff for internal use at the church only.



Participant Information:


Student’s Name: _____________________________________________   male        female

Birth Date: _____________________      Grade: ______      School: ________________________

Address: _______________________      City: ____________________     Area Code: __________

Parent(s)/Guardian Name(s): ______________________________________________________

Home Phone: ________________     Work: ___________________     Cell: ___________________

Pertinent medical information (including drug/food allergies, chronic conditions, current medications, other):




Medical # (9 digit): ________________   Doctor: ______________     Dr.’s phone: _____________


The emergency contact information for your child/youth is:

Name: _________________________________    Relationship to student:____________________

Address: _______________________      City: ____________________     Area Code: __________

Home Phone: ________________     Work: ___________________     Cell: ___________________



PERMISSION TO TRAVEL AND PARTICIPATE / LIABILITY RELEASE: I/We, the parent(s)/guardians of the above named student, do hereby give him/her permission to travel with the student group of Highland Community Church and to participate in all student activities and functions. We understand that our child may be traveling via public or private transportation (for example: car, bus, boat, van, plane). We hereby recognize the inherent risk associated with the various student activities and forms of travel, and agree to save and hold harmless Highland Community Church and their employees, volunteers, and agents from any liability or expense that may arise from my child’s participation in student events and any travel related incidents going to and from such event.


Note: In every instance where Highland Community Church members are using their personal vehicles for transporting minors to and from activities, the relevant ministry leader will ensure there are a valid driver’s license and a valid insurance policy with a minimum of $1 million liability coverage in place and that each driver is at least 18 years of age.


AUTHORIZATION OF CONSENT TO TREAT MINOR: In the event the above-named minor suffers an injury or condition during his or her participation in the activities, including transportation to and from the activity, which may endanger his or her life, cause disfigurement, physical impairment, or undue discomfort if medical treatment is delayed, and reasonable attempts to contact me have been unsuccessful, I hereby appoint eligible members of Highland Community Church leadership team as my agent(s) to act for me and in my name (in any way I could act in person) to consent to care which is deemed advisable by, and is to be rendered under the general or specific supervision of any physician or surgeon licensed under the provision of the Medical Practice Act, whether such diagnosis or treatment is rendered at the office of said physician or at a hospital. It is understood that this authorization is given in advance of any specific treatment or diagnosis, but is given to provide authority and power of treatment or hospital care which the aforementioned physician in the exercise of best judgment may deem advisable. This delegation of authority shall terminate when the agent is first able to contact me.


Release of Liability: I/We, the parent (s)/guardians of the above-named minor, shall indemnify, hold free and harmless, assume liability for, and defend Highland Community Church, its agents, servants, employees, officers, and directors from any and all costs and expenses including but not limited to, medical fees, attorney’s fees, discovery costs, court costs, and all other sums associated with any claim or action founded thereon, including those arising or alleged to have arisen out of treatment of aforementioned minor. I/We also release Highland Community Church and any agents of the church of any liability incurred due to aforementioned minor’s use of real or personal property belonging to Highland Community Church, its agents, employees, or volunteers.



________________________________________             __________________________

Signature of Parent/ Guardian                                           Date




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