4738 Walnut Grove Road Memphis, TN 38117Get Directions

Sunday Worship

Morning Services: 8:30 & 11 a.m.

Evening Service: 6 p.m. (most Sundays)

Sunday School: 9:45-10:45 a.m.

Dive-In Liability Release Form (2021)

Release of All Claims Please fill out the liability release form below in order for your child(ren) to participate. Enter your personal information first, followed by your child(ren)'s information last. (Only participants need to sign if aged 21 or older. If under 21, both parents must sign unless parents are separated or divorced, in which case the custodial parent must sign.)

Please enter your child(ren)'s info. below. :
*Participant's Full Name (1):
Participant's Full Name (2):
Participant's Full Name (3):
In consideration for being accepted by Independent Presbyterian Church for participation in Dive Ins and Water Days, we (I), being 21 years of age or older do for ourselves (myself) (and for and on behalf of my child-participant if said child is not 21 years of age or older) do hereby release, forever discharge and agree to hold harmless Independent Presbyterian Church, its employees, agents, and the directors thereof, from any and all liability, claims or demands for personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever, which may be incurred by the undersigned and the child-participant that occur while said child is participating in the above described trip or activity. :
Furthermore, we (I) (and on behalf of our (my) child-participant if under the age of 21 years)hereby assume all risk of personal injury, sickness, death, damage and expense as a result of participation in recreation and work activities involved therein. Further authorization and permission is hereby given to said church to furnish any necessary transportation, food and lodging for this participant. :
The undersigned further hereby agree to hold harmless and indemnify said church, its directors, employees and agents, for any liability sustained by said church as result of the negligent, willful or intentional acts of said participant, including expenses incurred attendant thereto. (If the participant has not attained the age of 21 years.) We (I) are the parent(s) or legal guardian(s) of this participant and hereby grant our (my) permission for him (her) to participate fully in said trip, and hereby give our (my) permission to take said participant to a doctor or hospital and hereby authorize medical treatment, including but not in limitation to emergency surgery or medical treatment, and assume the responsibility of all medical bills, if any. Further, should it be necessary for the participant to return home due to medical reason, disciplinary action or otherwise, we (I) hereby assume all transportation costs.:
*Primary Contact Cell Phone (Emergencies) :
*Alternate Contact Cell Phone (Emergencies) :
*Relationship to Child :
*Do you have hopsital insurance? :
*Health Insurance Company:
*Policy Number:
*Physician's Name:
*Physician's Phone:
*Parent's Electronic Signature (1):
*Parent's Electronic Signature (2):
*Today's Date:
I authorize IPC, its staff, employees, and volunteers to photograph or digitally record images of my child(ren) and to record my child(ren)’s voice during his /her participation and I authorize IPC to use such photos, images or recordings for any purpose relating to the IPC Children’s Ministry. I waive any and all privacy or intellectual property rights I or my child(ren) may have with respect to any such photos, images or recordings, and release IPC and its directors, officers, staff, employees, volunteers, agents and third party contractors, from any and all legal claims, demands or causes of action, of any nature whatsoever, relating to photos, images or recordings taken of my child(ren) pursuant to this authorization. :
The undersigned has read and agrees to be bound by this release of photograph or digitally recorded images of my child. The undersigned states on oath that he or she is the parent (custodial parent if divorced or separated) or legal guardian of the Participant and intends to be bound by this signature. :
*Parent or Legal Guardian's Electronic Signature: