1233 State Highway 66
Garland, Texas 75040
Returning this signed form confirms Participation
Release and Indemnification
Event: Travel to Texas A&M University, University of Houston, Texas Southern University
Date: Tuesday, October 4, 2011; Check In 4am; Departure Time: 4:30am
Cost: $10.00 Payable to Mt. Hebron Baptist Church:
Deadline: Wednesday, September 28, 2011
Bring FOOD to eat on the bus for LUNCH and money (approx. $6.00) for the evening meal. Submission of this Release and Payment of Reservation Fee, Secures Seat on the Bus
Participant:______Age:______Grade______
I agree, for myself, my heirs, executors and administrators, Church, its officers, directors, volunteers and employees from any and all liability, claims, demands, and causes of action whatsoever, arising out of my to not sue and to release, indemnify and hold harmless, the Mt. Hebron Missionary Baptist participation in this event and related activities--whether it results from the negligence of any of the above or from any other cause.
This release and indemnification agreement shall be as broad and inclusive as is permitted by the State in which the event is conducted. If any portion of it is held invalid, the balance shall continue in full force and effect.
I am legal guardian of Participant, and I hereby consent to his/her participation and the making of any medical decisions needed by the participant.
I have read the foregoing release and indemnification agreement, and I hereby agree on behalf of myself and Participant to its terms.
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Parent/Guardian's Signature Parent/Guardian's Printed Name
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Parent/Guardian's Phone Number Date
Parent’s EMAIL ADDRESS______
Return to Joyce Miller or 3114 Marilee Dr, Garland, Texas 75043 or the Church Office (Secure a receipt as proof of payment.).