Come, my children, listen to me; I will teach you the fear of the Lord  Psalm 34:11
 

KCHE Release Waiver

indicates a required answer

KCHE Liability Release and Hold Harmless Agreement

(I/we), being 21 years of age or older, do ourselves (myself) (and for and on behalf of myself and child-participant if said child is not 21 years of age or older) do hereby release, forever discharge and agree to hold harmless Kankakee Christian Home Educators group and the directors thereof, from any and all liability, claims or demands for any personal injury, sickness, Covid or death, as well as property damage and expenses, foreseen or unforeseen, of any nature whatsoever which may be incurred by the undersigned and the child-participant that occur while participating in the activities associated with the Kankakee Christian Home Educators group AKA KCHE.


Furthermore, we (I) (and on behalf of myself and our (my) child-participant if under the age of 21 years) hereby assume all risk of personal injury, sickness, Covid, death, damage and expense as a result of participation in the activities involved therein.


The undersigned further hereby agrees to hold harmless and indemnify said facility, its directors, employees and agents, for any liability sustained by said facility (or visiting facility) 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 ourselves and child him (her) to participate fully 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 I assume the responsibility of all medical bills, if any.


A medical release form maybe requested at the discretion of the KCHE board of directors, at anytime they deem for participation with KCHE and its affiliates.

1. *

(Include all members participating)


     Name:                                Age:                    Birth date:

 

2. *

Parent Email:

3. *

Hospital Insurance

4. *

Insurance Company and Policy Number

5. *

Physician and Physician's Phone Number:

6. *

Parents Phone Numbers (Home and cell):

7. *

Home Address (Please include City, State, and Zip):

8. *

Electronic Signature: