Horizon Christian Church

Permission Release & Hold Harmless Agreement

Student(s) Name(s) _______________________________________________________

Parent or Guardian Name, Address, Day & Night Phone Numbers

_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

In consideration of the participation of the minor(s) named above being permitted to participate in the Horizon Christian Church youth group activities during the year 2007.

If no one is available at the above phone numbers in case of an emergency, contact:

Name                                       Phone Number(s)                        Relation to Minor

______________________    ________________________    ______________________

______________________    ________________________    ______________________

______________________    ________________________    ______________________

I hereby agree to indemnify and hold harmless and blameless Horizon Christian Church, its officers, employees, agents, staff or volunteers from any and all liability from damages, loss or injuries, either to person or property, which the said minor may sustain while engaged in any activity conducted by or in connection with the Horizon Christian Church including but not limited to transportation.  I will not hold liable Horizon Christian Church including paid staff & volunteers for any injuries that may happen during this event including while playing, driving or attending activities.

I (We), the undersigned parent, parents or legal guardian of the above mentioned minor(s), do hereby authorize and consent to any x-ray examination, anesthetic, medical or surgical diagnosis and treatment and emergency hospital care which is deemed advisable by and is to be rendered under the general or special supervision of any member of the medical staff and emergency room staff.  It is understood that all reasonable effort shall be made to contact the undersigned prior to rending treatment to the patient, but that any of the above treatment will not be withheld if the undersigned cannot be reached.  I give permission to seek out appropriate medical care, if needed, including the use of anesthetics.  I further agree that, in the event of an accident, illness or any other circumstance requiring medical treatment procured for my son/daughter, I will be responsible for the financial costs of the treatment/care.

_________________________________________             _______________________

Parent or Guardian’s Signature                                                                          Date