Northshore Church Slidell, Louisiana

Permission/Hold Harmless

Agreement Statement

I, the undersigned parent or guardian of ______________________________________,

an applicant for participation in any and all activities sponsored by the Student Ministry

of Northshore Church, Slidell, Louisiana, do hereby state that said child is

physically and medically able to participate in the said activities from January 1, 2011

until December 31, 2011. I do hereby release and discharge Northshore Church,

Slidell, Louisiana and its authorized representatives and staff from all liability of any

kind and character upon any claim, demand, or cause of action which might be asserted

in behalf of said minor and or myself against Northshore Church, Slidell,

Louisiana, representatives, or staff. Furthermore, in the event of an accident, if the

said staff or representatives are unable to contact the undersigned, I hereby grant

permission to said staff or representative to administer necessary first aid, and/ or to

take the applicant to a medical facility for treatment.

Signed______________________________________

Phone (hm)________________(wk)_______________ (cell)_________________

Date________________________________________

Relationship to applicant________________________

Witness_____________________________________

Medications currently taken by the applicant and any allergic reactions for this applicant

must be listed below along with the applicant's Doctor's name and phone number.

MEDICATION___________________________________________________________

_____________________________________________________________________

ALLERGIC REACTIONS____________________________________________

________________________________________________________________

DOCTOR_____________________________PHONE_____________________

Notary Public

On this date the person(s) who are signed above personally appeared before

me, being personally know by me, and in my presence executed this

authorization and release from. Witness my hand and official seal this date

(____/____/____).

My commission expires _____/____/____

Signed ______________________________