FFC Chaperone Medical and Liability Release Form

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CHAPERONE MEDICAL/LIABILITY RELEASE AND GENERAL RELEASE FORM I, ______________________________________, in consideration of my acceptance as a chaperone on a trip Name

sponsored by FishHawk Fellowship Church to __________________________________________________ Destination of Trip

represent and agree that: 1. I am a participant on this trip and I am / am not going as an employee of FishHawk Fellowship Church. Circle One 2. I, ________________________________, on behalf of myself do hereby release FishHawk Fellowship Church of Lithia, Florida and its’ agents and employees (both paid and volunteer and all assistants, agents and contractors and staff) from liability in case of an accident or injury, even if resulting from the negligence of an agent or employee of FishHawk Fellowship Church. 3. Furthermore, I do hereby authorize the adult supervisors of FishHawk Fellowship Church to consent to any diagnosis or treatment and hospital care which is deemed advisable by, and is to be rendered under the general or special supervision of any licensed physician and/or surgeon. It is understood that this authorization is given in advance of any specific care being required, but is given to provide authority to give care which physician may, in the exercise of his/her best judgment, deem advisable, based upon such circumstances as exist, including but not limited to any emergency. 4. I hereby authorize FishHawk Fellowship Church, as well as its supervisors or volunteers, including those with training as Emergency Medical Technicians or Registered or Licensed Nurses, to perform care upon myself in accordance with the level of training they have received as deemed necessary by them. 5. I recognize and agree that all activities at or involving FishHawk Fellowship Church are physically, emotionally and spiritually beneficial, and also that every activity involves inherent and unavoidable risks. I have measured the risks against the benefits and I have determined that the benefits far outweigh the risks. 6. I have considered my ability to obtain independent insurance coverage or have other means to cover the expense of any loss, damage, or injury and I accept the risk and expense. 7. I hereby authorize the use by publication, display or public use of my photograph or any likeness in advertising, promotion, or reporting of events of FishHawk Fellowship Church or any activity in which FishHawk Fellowship Church is associated, and I hereby waive and release any and all claims, rights and claims for damages I may have against FishHawk Fellowship Church or against its agents, employees, volunteers and contractors from any and all claims, damages or actions of any nature whatsoever, including but not limited to claims pursuant to Chapter 540, Florida Statutes, as a result of such use or display. 8. This release form and the authorizations above shall remain effective until revoked in writing and delivered to FishHawk Fellowship Church with the understanding that the participation in any requested activity thereafter may take place only with a fully executed and valid form in the possession of FishHawk Fellowship Church.

PLEASE FILL OUT AND SIGN PAGE 2

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MY INFORMATION Name

Soc. Sec. Num. ____________________ Date of Birth ___/ ___ / ________

Address

City

State

Zip _____________

Phone __________________________ Cell Phone ______________________________ Employer __________________________________ Address ______________________________________________________ Medical Insurance Carrier ____________________________________ ID # ____________________ Group # ______________ Insurance Phone Number ___________________________ Family Physician _____________________________ Phone _____________________________________

MEDICAL INFORMATION (Please check and specify any past history or condition below) _____Allergies (please list below)

_____Asthma ____Diabetes _____Heart Condition _____Hypoglycemia

_____Epilepsy or other nervous disorders _____Bleeding Disorder _____Other (list below) ______Date of last Tetanus Shot ___________________________________________________________________________________________________________ ___________________________________________________________________________________________________________

List all current medications: __________________________________________________________________ _________________________________________________________________________________________

SIGNATURE I expressly agree that this assumption of risk agreement is intended to be as broad and inclusive as permitted by law. I further state that I HAVE CAREFULLY READ THE FOREGOING WAIVER OF LIABILITY AND UNDERSTAND ITS CONTENTS, AND I VOLUNTARILY SIGN THIS RELEASE AS MY OWN FREE ACT. THIS IS A LEGAL DOCUMENT. I UNDERSTAND THAT I HAVE THE OPPORTUNITY TO CONSULT WITH AN ATTORNEY BEFORE SIGNING IT. Signature_____________________________________________ Date: ___________________ Sworn to and ascribed before me this ______ day of ________________ , 20___, personally appeared ___________________________, who is known to me personally or who provided me with a Florida Driver’s License _________________________, as identification and who is known to be the person completing this Medical Release Form. __________________________________________ Notary Public, State of Florida

My Commission Expires: _____________________________