Parental Release / Medical Authorization and Agreement to Pay Medical Expenses

This permission slip covers the calendar year for ALL EVENTS on or off campus related to Lebanon Calvary Chapel Youth Groups (MISFITS & SOULED OUT)(excluding Youth Retreats) between the dates January 1st, 2024-December 31, 2024 that the child listed below is in attendance. You will receive a call to confirm that you the Legal Guardian were the one who filled this out. Thank you!

Child's Name

Legal Guardian Name

I authorize Lebanon Calvary Chapel to be my child’s agent for medical treatment purposes. I authorize Lebanon Calvary Chapel staff or leaders to obtain any medical advice or treatment reasonably necessary during my child’s participation in Lebanon Calvary Chapel Youth Events. In the event of emergency, this authorization includes but is not limited to the expenses of any necessary ambulance, hospitalization, x-rays, anesthesiology and/or surgery.

Agree

Disagree

I release Lebanon Calvary Chapel from all claims, causes of action or damages which I or my child might have as a result of participating in Lebanon Calvary Chapel Youth Events that I approve below and I agree to save and hold Lebanon Calvary Chapel harmless from those claims, causes of action or damages.

Agree

Disagree

I give my consent in advance of any specific diagnosis, treatment or hospital care required. I understand that if medical treatment is necessary for my child, Lebanon Calvary Chapel must rely on the advice of the physician involved, and on the exercise of the physician’s best medical judgment.

Agree

Disagree

I agree to pay all expenses incurred in providing medical treatment to my child under this agreement, and to reimburse Lebanon Calvary Chapel for any medical expenses paid.. I specifically save and hold Lebanon Calvary Chapel harmless from responsibility for those expenses.

Agree

Disagree

I give Lebanon Calvary Chapel permission to use photos & video for any legal use, including but not limited to: publicity, illustration, advertising and web content (social media/website).

Agree

Disagree

Name of Insurance Carrier

Insurance Carrier Phone Number

Physician

Policy Number

Effective Date

Emergency Contact Name & Number

Primary Contact Name and Number

Does your child need medication that may be needed at any event?

Signature

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