ADULT MEDICAL & LIABILITY RELEASE FORM
The form will be kept on file during theyouth ministry program year . Please update any change in telephone number/contact numbers prior to any church sponsored trips. All participants must have a completed form on file in order to participate on any retreat, mission trip, or event involving leaving the church premises.
Saint Luke’s Presbyterian Church • 1978 Mt. Vernon Rd • Dunwoody, GA 30338
FAX: 770-393-3278 • Phone: 770-393-1424
This forms gives the group leaders authorization to secure medical aid for you should it be necessary.
I hereby authorize any hospital, clinic, physician, doctor, nurse or technician to furnish me any medical care treatment necessary as a result of injuries sustained or other emergency medical treatment as the circumstances require while being transported from and back to the church, and while at the place of destination. I hereby authorize a representative of the Saint Luke’s Presbyterian Church to retain or acquire said medical care and treatment on my behalf if I am unable to make that decision. I agree not to hold such a person responsible for any damages rising from the giving of such consent.
Today's Date: April 19, 2024
I understand that as a participant, I may be photographed or videotaped during normal event, camp, or mission activities and these photos/videos may be used in promotional materials and give my permission for my likeness to be used in such materials.