Permission and Release Form

Permission and Release Form
I hereby give my consent for
to participate in the
following activity of The Stone Church, Cartersville, Georgia;
I understand that insurance coverage for accidental injury or sickness will not be
provided by The Stone Church and I agree that I will be responsible for any medical
expenses that might be incurred because of accident or illness.
I hereby release The Stone Church, Cartersville, Georgia, its agents, employees, or
volunteer workers from any liability for accidental injury or sickness which may
occur to the above person while participating in the above activity, including
transportation to and from. I also give my consent to the sponsors to authorize
emergency medical treatment for the above participant while trying to contact me at
one of the phone numbers listed.
If the above person is required to leave in advance of the time when any furnished
transportation leaves, either for medical reasons or for discipline reasons, then I
agree to arrange and pay for the transportation back.
Home Phone (
Cell or Emergency Contact #
day of
Signature of Parent or Guardian
, 20
Print Name