Liberty Bible ChurchAdult Medical Release Name * First Name Last Name Home Address * Address 1 Address 2 City State/Province Zip/Postal Code Country Home or Cell Phone * (###) ### #### Home or Cell Phone (###) ### #### Email Birth Date MM DD YYYY Emergency Contact Info Emergency Contact Name * First Name Last Name Emergency Contact Home or Cell Phone * (###) ### #### Emergency Contact Email Medical Information & Release Insurance Carrier Name of Policy Holder Policy / Group Number List all known medical conditions * List any important medications currently taking I understand that there are inherent risks involved in any ministry event, and I hereby release Liberty Bible Church, its pastors, employees, agents, and volunteer workers from any and all liability for any injury, loss, or damage to person or property that may occur during the course of my involvement. I affirm that the health insurance and medical information provided is accurate at this time. If this information changes, I will notify Liberty Bible Church as soon as possible. In the event that I am injured and require the attention of a doctor, I consent to any reasonable medical treatment as deemed necessary by a licensed physician. I acknowledge that I will be ultimately responsible for the cost of any medical care should the cost of that medical care not be reimbursed by my health insurance provider. Should it be necessary for me to return home from an event for medical or other reasons, I will also assume all transportation costs. Checking "Yes" below is considered your digital signature for the purposes of this authorization. By checking here, you are consenting to the use of your digital signature in lieu of an original signature on paper. You have the right to request that you sign on a paper copy instead. By checking "Yes" below, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. Your agreement to use a digital signature with us will continue for the full duration of 2025 or until you notify us in writing that you no longer wish to use a digital signature. Name * First Name Last Name Date Submitted * MM DD YYYY Digital Signature * Yes Submission of this form indicates that you understand what is contained in this authorization. This authorization shall remain in effect for the full duration of 2025 unless sooner revoked in writing. If you would prefer a paper copy of this form, one can be obtained from the church office during business hours. Thank you. Your medical release has been placed on file and will stay in effect for the remainder of the current calendar year.
