LIABILITY RELEASE, WAIVER & INDEMNITY AGREEMENT

    IT IS THE INTENTION OF (Parent or Guardian)_________________________________ BY THIS AGREEMENT TO EXEMPT AND RELIEVE  William K. and LaVerne J. Blickley, doing volunteer work as: Wherever God Wills youth group support service, with their motor home/bus ,  AND ITS OFFICERS, AGENTS, OR VOLUNTEERS FROM LIABILITY FOR  PROPERTY DAMAGE,  WRONGFUL DEATH, OR PERSONAL INJURY OF (Child's name) ___________________________  CAUSED BY ANY ACT OF NEGLIGENCE OF  this volunteer support service  AND ITS OFFICERS, AGENTS, OR VOLUNTEERS.
       I understand that our church/organization youth group leaders are responsible for programming, the organization, and the supervision of our group members, and that our youth group is insured for any personal injury liability.
(Note: Because of Michigan's no-fault law, any personal medical care required by an auto-accident injury, is paid for by each individual's auto insurance.)

DATED: ___________________

PARENT OR GUARDIAN : Phone #_____________________Work #_____________________Cell #_____________________

(Signature) Mother: ___________________________ Father: ________________________Guardian:__________________

(Print) Mother:__________________________ Father: _________________________ Guardian:_______________________

Street Address: _____________________________ City: ____________________State:_______ E-Mail ________________

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