Adult - Field Trip Liability Waiver Form

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Ignite Conference 2020

Email *

I, *

First Name *

Last Name *

agree on behalf of myself, my heirs, assigns, executors, and personal representatives, to hold harmless and defend St. Matthew Catholic Church, the Diocese of Charlotte, and its officers, directors, agents, employees, or representatives associated with the field trip from any and all liability claims, loss or damage arising from or in connection with my participation in the field trip.

In the event that I should require medical treatment and I am not able to communicate my desires to attending physicians or other medical personnel, I give permission for the necessary emergency treatment to be administered.

Please advise the doctors that I have the following allergies:

Please indicate N/A if not applicable.

In case of an emergency and for permission for treatment beyond emergency procedures, please contact:

Name: *

Relationship to me: *

Daytime Phone: *

Night time Phone: *

Health Insurance Carrier: *

Insurance ID Number: *

Insurance Policy Number: *

CONSENT: I agree to the above: *

I agree

Required

Date: *

YYYY

Send me a copy of my responses.

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