330 Hookstown Grade Rd, Moon Twp, PA 15108, (412) 264-9392
Study Care Program Liability Release Form
Release of All Claims

In consideration for being accepted by Impact Christian Church of Moon Township, PA for participation in the Study Care Program sponsored or attended on or between August 24, 2020 to May 31, 2021, we do hereby release, forever discharge and agree to hold harmless Impact Christian Church 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 the trips or activities noted above.

Furthermore, we hereby assume all risk of personal injury, sickness, death, damage and expenses as a result of participation in recreation and work activities involved therein.

Coronavirus / COVID-19 Warning & Disclaimer

Coronavirus, COVID-19 is an extremely contagious virus that spreads easily through person-to-person contact. Federal and state authorities recommend social distancing as a mean to prevent the spread of the virus. COVID19 can lead to severe illness, personal injury, permanent disability, and death. Participating in IMPACT CHRISTIAN CHURCH OF MOON TOWNSHIP programs or accessing IMPACT CHRISTIAN CHURCH OF MOON TOWNSHIP facilities could increase the risk of contracting COVID-19. IMPACT CHRISTIAN CHURCH OF MOON TOWNSHIP in no way warrants that COVID-19 infection will not occur through participation in IMPACT CHRISTIAN CHURCH OF MOON TOWNSHIP programs or accessing IMPACT CHRISTIAN CHURCH OF MOON TOWNSHIP facilities.

The undersigned further hereby agree to hold harmless and indemnify said church, its directors, employees and agents, for any liability sustained by such church as the result of negligent, willful, or intentional acts of said participant, including expenses incurred attendant thereto.

We are the parents or legal guardians of this participant, and hereby grant our permission for him/her to participate fully in any activity, and hereby give our 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 reason, disciplinary action or otherwise, we hereby assume all transportation costs.

Child #1:
First and Last Name: [Participant-1] Age: [Participant-1-age]
Child #2:
First and Last Name: [Participant-2] Age: [Participant-2-age]
Child #3:
First and Last Name: [Participant-3] Age: [Participant-3-age]
Other Participants:
[Other-Participants]

Digital Signature:
I hereby affirm the information provided above is accurate: [Affirmation]
Today's Date: [Today]
Initials and First/Middle/Last Name (i.e., JDS John Dean Smith):
[Signature]
Form Version Date: 08/14/2020