St. Matthew's Church

Medical Release and Authorization Form

I give permission for ______________________________ to participate in the following event, ______________________________________, sponsored by St. Matthew's Church on the following date/s ________________________. I give my permission to engage in all activities except as noted on the bottom of this form. I also give permission for photographs of my child to be used by the St. Matthew’s Church for promotional or other purposes.

In case of medical emergency, I understand that every effort will be made to contact the parent or guardian. In the event that I cannot be reached, I hereby authorize and consent to any x-ray, examination, anesthetic, medical or surgical diagnosis or treatment and hospital care which is deemed advisable by, and is to be rendered under the general or special supervision of any licensed EMT, or licensed medical personnel on the staff of any licensed medical facility. This authorization is given in advance of any specific diagnosis, treatment or hospital care required, but is given to provide authority and power to render care which is deemed advisable in the best judgment of the EMT or physician. I am responsible for payment of all fees incurred.

I hereby indemnify, agree to hold harmless, and waive any claim against the Congregation named above, the Episcopal Diocese of New York, its members, representatives, officers, agents, employees, directors, and each of them, for any and all past, present or future loss to property, and/or bodily injury resulting from any activities engaged.

DATE: ________ SIGNATURE: _____________________ RELATIONSHIP: _____________