Medical and Liability Waiver Form

Please fill out the form below. If you have any questions, feel free to email Director of Children & Family Ministries, Brie Johnson
Are there any physical limitations/health history that would affect the ability for your student to participate in any Youth Activities.
List All Medications (Prescribed & OTC) and reason for medication.

I give permission for my student to participate with other youth and adults from First Presbyterian Church of Livermore (FPCL) at the event listed on this form. In the unlikely event of an emergency, I give permission for my student to be treated by an accredited physician in an approved emergency clinic or hospital. I designate the adult leaders for the group with the authority to act on my behalf and order appropriate treatment. I further release from any liability the San Francisco Presbytery (SFP) and FPCL and its officers and approved emergency clinic leadership, in the event of any accident en route during and returning from these events.I expect to be contacted as soon as possible. *If we cannot provide proof of medical insurance, my name in this form acts as my signature for the waiver releasing liability below.

NOTE: Please complete and sign ONLY IF YOU DO NOT have medical insurance for your student.
I understand that by my child attending any youth events that FPCL and SFP will not be responsible for any emergency medical expenses incurred.
I also understand that FPCL and SFP will not be held liable for my child's actions that might involve a lawsuit.