Cornerstone Trinity Baptist Church www.cornerstonetrinity.

org

LIABILITY FORM
General Trip Information

Maywood Park, 3300 Pruneridge Avenue,

Date(s) of Trip: June 4th, 2011 Location of Trip: Santa Clara, 95051
Leaders/Sponsors
Cell Phone: Pastor Kevin Wong 415.279.3269
Emergency Contact Information
Relationship to
Name: attendee:
Alternate/
Work Phone: ( ) Cell Phone: ( )

Medical Information

Medical Insurance Company:

Policy/Subscriber # No Medical Coverage
Please list any allergies you may have. If none, write none:
Allergies:
List out any medication taken or allergies to any medication:
Medication:
Other Medical Please list any other medical conditions
Information:

Liability Waiver
PLEASE INITIAL:
___ I will not hold Cornerstone Trinity Baptist Church or its agents liable for injury caused by
common accident, illness or the rendering of emergency care.
___ I understand that Cornerstone Trinity Baptist Church assumes no financial liability for any
accident or injury that may occur during the trip, en route to the destination, or en route from the
destination. I authorize medical treatment to be given to me in the event I am not conscious. In the
event of a claim, family insurance, if any, may be partially liable.
___ I give permission for Cornerstone Trinity Baptist Church to use any pictures or video taken for
future use.
Signature: ________________________________ Date: ____________

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For parents to keep as reference:

TO: Maywood Park, 3300 Pruneridge Avenue, Santa Clara, CA

DATE: Saturday, June 4th, 2011

In case of an emergency and you need to reach your child please contact the following
leaders/sponsors:

Pastor Kevin Wong – 415.279.3269

Cornerstone Trinity Baptist Church 1900 Lawton Street SF, CA 94122 ph: 415.566.5756