TO WHOM IT MAY CONCERN:
By typing my name above, I hereby give permission for our (my) son/daughter, to attend and participate in VBS sponsored by West E Free Church during the week of June 8-June 12, 2015.
We (I) authorize an adult, in whose care the minor has been entrusted, to consent to any x ray examination, anesthetic, medical, surgical or dental diagnosis or treatment, and hospital care, to be rendered to the minor under the general or special supervision and on the advice of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital and/or emergency care facility, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital. We (I) do hereby authorize the treatment by this authority, and it is granted only after a reasonable effort has been made to reach us/me, the parent(s) and/or guardian(s).
We (I) the undersigned shall be liable and agree to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child pursuant to this authorization. Should it be necessary for our (my) child to return home due to medical reasons or otherwise, the undersigned shall assume all transportation costs.
My (Our) signature also serves to indicate my (our) willingness to take full financial responsibility for any and all medical services rendered for the named participant. My (Our) signature also serves to indicate my willingness for my (our) health insurance company; to be billed for any and all medical fees and services should they be needed. We (I) hereby release the named church from this liability.
The undersigned does hereby release and agree to hold harmless West E Free Church and their directors, employees, agents, or representatives from any and all liabilities or claims for personal injury, illness or death, as well as property damage and expenses of any nature whatsoever that may be incurred by our (my) son/daughter that occur within the effective dates stated above and/or while said child is participating in the above-named event and its activities.