Believers’ Home Education

Release of Liability Statement

Believers’ Home Education is made up of those who have volunteered their time to organize activities for the
group. Neither our group, nor its leaders, nor its members are liable for any injuries or damages, whether
connected with Believers’ Home Education or not.

At all events, parents are completely responsible for their own child(ren). No child is permitted to attend any
event without the accompaniment and supervision of their own parent, unless other arrangements are made. If
at any time a parent sends a child to an event without their accompaniment that child(ren)becomes the
sole responsibility of the adult assigned to them. It is absolutely essential that the parent send a medical
release notice with the child. Any guests to a Believers’ Home Education event are the sole responsibility
of the adult inviting them.

It is expected that any participant or his child or guest who damages property or who causes injury, either
willfully or through neglect, will take personal responsibility for his actions. Any person who has such a claim
will be directed to discuss the offense individually with the other party. If such disputes cannot be handled by
the parties individually, we expect them to follow the requirements of Matthew 18:15-20.

Please make copies of the following Medical Consent Form and fill one out for each of your children. It is
very helpful to include copies of your insurance cards. You may want to keep a copy for your records.

My signature at the bottom of the Medical Consent Form indicates:

I acknowledge and fully understand that there are risks of injury during Believers’ Home Education activities
and that severe injury could occur.

I assume all the foregoing risks and accept personal responsibility for the damages following injuries of myself,
my child(ren) and/or guests.

I release, waive and discharge all volunteers, leaders, organizers and helpers from liability for injury of any
nature and property damages that may occur as a result of participating in Believers’ Home Education.

_________________________________________ _____________________________________
Print Name Print Name

_________________________________________ _____________________________________
Signature and date Signature and date
 Believers’ Home Education
Medical Consent Form
Authorization by parents for another to consent to hospitalization, surgery, or special medical
procedures for minor child during absence or incapacitation of parents.

Parents:_______________________________________ ___________________________________________
Full names of both parents

Address:__________________________________________________________________________________
Complete address of both parents including street, city, state, and zip code

Phone: (Home)_________________ Mom’s Cell_____________________ Dad’sCell____________________

List any and all phone numbers where parents can be reached

Information about the child:

Full Name: ________________________________________________________________________________
Birth date: _____ - _____ - ______ Blood Type: ____
Any known allergies: _______________________________________________________________________
Any medical conditions or considerations: (Eye wear, etc .) _________________________________________
_________________________________________________________________________________________
Medications:_______________________________________________________________________________
Pediatrician/Physician: ___________________________________ ___________________________________
Full Name Phone number including area code
_________________________________________________________________________________________
Complete address

Insurance Information:_______________________________________________________________________
Insurance Carrier
________________________________________________ __________________________________________________________
Policy and/or group numbers Insurance Phone Numbers including area codes

Alternate Emergency Contact ___________________ _______________________ _____________________

Full Name Phone number including Relationship

Alternate Emergency Contact ___________________ _______________________ _____________________

Full Name Phone number including Relationship

We hereby appoint any adult volunteer from Believers’ Home Education as the person who, during our absence
or incapacity, shall be authorized to consent for all medical and/or surgical treatment and/or special procedures.
If circumstances permit, our doctor is to be consulted in connection with such medical and/or surgical treatment
and/or special procedures. Any physicians providing medical or surgical services to my child may rely upon the
consent of authorization executed by the Believers’ Home Education volunteer with the same force and effect as
if personally executed by us. The consent and authorization shall include and extend to all for which consent or
authorization is required except organ donation and/or removal of life support systems. In consideration for the
services which are rendered to my child, pursuant hereto, we agree to pay for all such services. This
authorization shall be effective until revoked.

_________________________________________ _____________________________________
Signature and date Signature and date