Focus on the Family
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Liability Release Form
Name:________________________________ Age:____ Phone:_________
Address:__________________________________ City:________ Zip:____
Parents Phone # _______________________________________________
Cell #________________________ Work #_________________________
Hospital Insurance? Yes__ No___
Insurance Co._________________________ Policy #__________________
Doctor’s name & phone__________________________________________
Emergency Contact (name & phone)________________________________
My Son/Daughter has my permission to attend any of the events or retreats sponsored by the Cross Point Free Will Baptist Church during the Calendar years of 2012-2013. I release the sponsoring church, The Cross Point Free Will Baptist Church, and all individuals representing said church, of liability for an accident that might occur to my son/daughter while participating in events. I also agree to allow emergency medical treatment for my child, if a medical emergency should arise. I understand that should my child be sent home from any event, I could be called upon to provide transportation home from such event.
Parent or guardian
Signed before me this______ day, of ______________ year of_______. State of KS County of SG