Statement of Agreement

I understand that in the event medical intervention is needed, every attempt will be made to contact the persons listed on this form. In the event I cannot be reached in an emergency, I herby give permission to the physician or dentist selected by the activity leader to hospitalize, to secure medical treatment and/or order an injection, anesthesia, or surgery for my child as deemed necessary.

I understand that my insurance coverage for my child will be used as primary coverage in the event medical intervention is needed. Coverage by Faith Chapel through its liability policy will be used as excess for what my family’s insurance does not cover.

I understand all reasonable safety precautions will be taken at all times by Faith Chapel and its agents. I under the possibility of unforeseen hazards and know the inherent possibility of risk. I agree not to hold Faith Chapel , its leaders, employees, and volunteer staff liable for damages, losses, diseases, or injuries incurred by the subject of this form.

By filling out the form below, I am indicating that I agree to the statement above.