We authorize the Youth Worker, in whose care our teen/child has been entrusted, to consent to any X-ray examinations, anesthetic, medical, surgical, or dental diagnosis or treatment, and hospital care, to be rendered to our teen/child under the provisions of the Medical Practice Act on the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital.
The undersigned shall be liable and agrees to pay all costs and expenses incurred in connection with such medical and dental service rendered to the aforementioned teen/child pursuant of this authorization.
Every activity sponsored by this church is carefully planned and adequately supervised by mature adults; however even with the best planning and precaution, unforeseen events can occur.  By signing this form, the parent or legal guardian agrees to assume and accept all risk and hazards inherent in church-related social activities.  They also agree not to hold this church or its employees or volunteer assistants liable for damages, losses, or injuries to the person or property of the undersigned.  The parents or legal guardians understand that they are signing for the minor listed on this form and the signature is both a medical and liability release.
Should it be necessary for your child to return home due to medical reasons or otherwise, the undersigned shall assume all transportation costs.