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Robertsdale United Methodist Church

P.O. Box 866 Robertsdale, AL 36567 Phone (251)947-4602 Fax (251) 947-4445

Dear Parent or Legal Guardian:If you would like your child to participate in this event that requires transportation to alocation away from Robertsdale United Methodist Church please complete, sign, and return thisstatement of consent and release of liability. As a legal guardian, you remain legallyresponsible for any personal actions taken by the named minor (“participant”). This activity will take place under the guidance and supervision of employees and/or from theRobertsdale United Methodist Church. A brief description of the activity as follows: Participant’s Name: ____________________________________ Birth Date: ______________________Parent/Guardian name: (please print) ______________________________________________________Address: _____________________________________________________________________________Cell Phone: ______________________________ Other Phone: ____________________________ I agree on behalf of myself, my child named herein, or our heirs, successors, and assigns, tohold harmless and defend Robertsdale United Methodist Church, its officers, directors,employees and agents, from any claim arising from or in connection with my child attendingthe event or in connection with any illness or injury (including death) or cost of medicaltreatment in connection therewith, and I agree to compensate Robertsdale United MethodistChurch, its officers, directors and agents, its employees and agents and chaperones, orrepresentative associated with the event for reasonable attorney’s fees and expenses that mayincur in any action brought against them as a result of such injury or damage, unless such claimarises from the negligence of Robertsdale United Methodist Church. MEDICAL MATTERS: I hereby warrant to the best of my knowledge, my child is in good health,and I assume all responsibility for the health of my child.

Emergency Medical Treatment

: In the event of an emergency, I hereby give permission totransport my child to a hospital for emergency medical or surgical treatment. I wish to beadvised prior to any further treatment by the hospital or doctor. In the event of an emergency, if you are unable to reach me at the above numbers, contact:Emergency contact name (please print): _______________________________________Relationship to participant: _________________________________________________Cell phone: _____________________________ Other Phone: _____________________Any other Specific Medical Information (i.e. allergies, history of seizures, current medications) __________________________________________________________________________________ __________________________________________________________________________________ ______ __________________________________________________________________________________ ___ Parent/Legal Guardian Signature: _____________________________________ Date: _______________

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Type of event:

Angel Food Ministries Distribution

Destination:

Thames Senior Center, Robertsdale, AL

Individual in charge:

Eddie Pratt – Youth Director

Angel Food Ministries Distribution, Robertsdale, AL