Youth/Child Indemnification

Release and Medical Consent Form

This form is used in conjunction with all youth activities sponsored by the SC Family Ministry. The form will be effective immediately and will remain in effect for one year from the date of signing. This form must be filled out for all minor children participating in all church activities where parents/guardians are not present, including worship rehearsals, fellowship sessions and any off-site or overnight activities organized by Steele Creek Church of Charlotte

I *
Parent of Legal Guardian
Child's Name *
Child's Name
Age *
Date of Birth
is, with my permission, enrolled in one or more Steele Creek Church of Charlotte church, school, youth fellowship or choir programs.
Medical Treatment I hereby authorize the applicable employee of Steele Creek Church or any other adult acting as an agent or representative of Steele Creek Church to take any and all actions that may be necessary or proper to provide for, or arrange for the provision of, the health care of such minor, including, but not limited to, (i) providing over the counter medication and assisting in administering such minor’s prescription medications as needed, (ii) providing for such health care at any hospital or other institution, or employing any physician, dentist, nurse, or other person for such health care, and (iii) consenting to and authorizing any health care, including but not limited to the administration of anesthesia, the taking of X-rays, the performance of tests and operations, and other procedures, by physicians, dentists, nurses, and other medical personnel. I agree to be responsible for any and all charges incurred in connection with any care or treatment rendered pursuant to this authorization, even if an employee, agent or representative of Steele Creek Church has signed documentation promising to pay for such care or treatment. Indemnification and Release On behalf of the minor listed above, I agree to defend, hold harmless, indemnify and release Steele Creek Church and its officers, trustees, employees, agents, representatives, volunteers, and all others who are involved in the Programs from and against any and all claims, demands, actions, or causes of action of any sort on account of damage to personal property, or personal injury, or death which may result from such minor’s participation in the Program. This release includes claims based on the negligence of Steele Creek Church and its officers, trustees, employees, agents, representatives, and volunteers, but expressly does not include claims based on their intentional misconduct or gross negligence.
Photographs *
give permission for such minor’s photo to be taken by Church staff or volunteers during activities of the Program, with the understanding that pictures might be used in Steele Creek Church or community publications. Note that Steele Creek Church does not control the taking of photographs by other participants.
Transportation *
I give Steele Creek Church permission to arrange necessary related transportation for such minor.
The signer acknowledges that Steele Creek Church does not guarantee that the preferred hospital will be utilized.
Signature *