LIABILITY RELEASE FORM

NAME                                       GENDER                          AGE

NAME                                       GENDER                          AGE

To participate in and abide by the rules governing the program / activity.
This activity is scheduled to begin at:

McLeod’s Residence in Woodlawn,               6:30 PM              Friday, October 8rd, 2004
Place                                        Time                            Date

and end at:

McLeod’s Residence in Woodlawn,              11:00 AM              Saturday, October 9th, 2004
Place                                        Time                            Date

                                       HEALTH HISTORY
 ______ Food Allergies _____________________________________________________________________
 ______ Drug Allergies _____________________________________________________________________
 ______ Chronic Asthma ____________________________________________________________________
 ______ Hay Fever       _____________________________________________________________________
 ______ Diabetes        _____________________________________________________________________
 ______ Other           _____________________________________________________________________
 Activity Restrictions: _____________________________________________________________________
 Physician:             _____________________________________________________________________
 Physician’s Telephone ____________________________________________________________________
 Health Card Number: _____________________________________________________________________
 Last Tetanus Shot: _____________________________________________________________________

I will convey to my child(ren) my expectation that (s)he/they will abide by the rules governing
the activity. I recognize the importance of prompt pick up of my child(ren) upon completion of
the activity. I agree to allow the leaders of this activity to authorize medical treatment for my
child(ren) if I cannot be reached at one of the numbers listed and I will assume any medical bills.

_______________________________________          Tel (H)_________________(W)_________________
     Signature of Father or Guardian

_______________________________________          Tel (H)_________________(W)_________________
     Signature of Mother

________________________________________         ____________________     _______________________
     Emergency Phone Number                            Telephone                    Date
In consideration for being accepted by Metropolitan Bible Church for participation in (Christian
Service Brigade) CSB Camp Out, we (I), being 21 years of age or over, do for ourselves (myself)
(and for and on behalf of my child participant, if said child is not 21 years of age or older) do
hereby release, forever discharge and agree to hold harmless Metropolitan Bible Church and the
directors thereof, from any and all liability, claims or demands for personal injury, sickness,
death, as well as property damage and expenses, of any nature whatsoever which may be
incurred by the undersigned and the child participant that occur while said child is participating
in the above described trip or activity.

Furthermore, we (I) hereby assume all risk of personal injury, sickness, death, damage and
expense as a result of participation in recreation and work activities involved therein.
Further, authorization and permission is hereby given to said church to furnish any necessary
transportation, food and lodging for this participant.

The undersigned further hereby agrees to hold harmless and indemnify said church, its directors,
employees and agents for any liability sustained by the church as the result of the negligent,
willful or intentional acts of said participant, including expenses incurred attendant thereto.

If the participant has not attained the age of 21 years

I am a parent or legal guardian of this participant and herby grant my permission for him (her) to
participate fully in said trip. Should it be necessary for the participant to return home due to
medical reasons, disciplinary action or otherwise, we (I) hereby assume all transportation costs.

_____________________________________________________________       __________________________________
           Custodial Parent / Legal Guardian                                       Date

                                      Trip Participant Only

 I have read the foregoing and understand the rules of conduct for participants and will
       abide by them, and will abide by the directions of the leadership of the trip.

  ___________________________________________         ____________________________________________
        Participant’s Signature                                  Date

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