Youth Liability Release Form


Download the PBC Liability Release Form 2017-18 (pdf)

Release of all claims
In consideration for being accepted by Ponderosa Basin Chapel for participation in youth activities held during the 2017-18 school year and following summer, we (I), being 21 years of age or older, do for ourselves (myself) (and for and on behalf of my child-participant if said child is not 21 years of age or older) do hereby release, forever discharge and agree to hold harmless Ponderosa  Basin Chapel and the directors thereof from any and all liability, claims or demands for personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the child-participant that occur while said child is participating in any trip or activity this year.

Furthermore, we (I) (and on behalf of our (my) child-participant if under the age 21 years) hereby assume all risk of personal injury, sickness, death, damage and expense as a result of participation in recreation and work activities involved therein.
Further, authorization and permission is hereby given to said church to furnish any necessary transportation, food, and lodging for this participant.

The undersigned further hereby agree to hold harmless and indemnify said church, its directors, employees and agents, for any liability sustained by said church as the result of the negligent, willful or intentional acts of said participant, including expenses incurred attendant thereto.
If the participant has not attained the age of 21 years:
We (I) are the parent(s) or legal guardian(s) of this participant, and hereby grant our (my) permission for him (her) to participate fully in said trips or activities, and hereby give our (my) permission to take said participant to a doctor or hospital and hereby authorize medical treatment, including but not in limitation to emergency surgery or medical treatment, and assume the responsibility of all medical bills, if any.
Further, should it be necessary for the participant to return home due to medical reasons, disciplinary action or otherwise, we (I) hereby assume all transportation costs.

Type or print name of participant:

(Only participant need sign if 21 years of age or older. If under 21, both parents must sign unless parents are separated or divorced in which case the custodial parent must sign)
Parent(s) Telephone:

Father’s Signature and Date:

Mother’s Signature and Date:

Legal Guardian’s Signature and Date:

Participant’s Signature , if age 21, and Date:

Hospital Insurance: (circle one) YES NO

Insurance Company:

Policy Number:


Physician’s Phone:

Emergency phone numbers:

Allergies or chronic health problems: