Medical & Liability Release Form


This must be completed in its entirety and submitted for you/your child to participate in activities sponsored by Coppell Bible. This form is good for one year from the date of submission. If your information has changed, please complete this form to update us or contact Margie.

It is our policy at Coppell Bible to contact the Parent/Guardian or Emergency Contact as soon as possible in the event of a serious accident or injury.


My Health Info











Click Next to input your Medical Insurance Info

Medical Insurance Info


Your carrier will be billed for medical charges in the case of illness or injury while you are involved in a church-related activity.

Click Next to input your Emergency Contact Info

Emergency Contact Info


Click Next to read & sign our Liability Release

Liability Release

I, being at least 18 years of age or older, do for myself hereby release, forever discharge and agree to hold harmless Coppell Bible, as well as its pastors, elders, employees, and volunteers from any and all liability, claims or demands for personal injury, sickness or death, as well as property damages and expenses, of any nature whatsoever which may be incurred by me that occur while participating in any church trip or activity. Furthermore, I hereby assume all risk of personal injury, sickness, death, damage and expense as a result of participation in such trip or activity. I further agree to hold harmless and indemnify Coppell Bible, its pastors, elders, employees and volunteers for any liability sustained as the result of negligent, willful or intentional acts of any participant, including expenses incurred attendant thereto.


Name of Signature Above

Parent/Guardian Info


Click Next to fill out an Emergency Contact Info if the Parent/Guardian cannot be reached in the event of an emergency

Emergency Contact Info

IF PARENT/GUARDIAN CANNOT BE REACHED in the event of an emergency, contact:

Click Next to fill out your Child's Health Info

Child Health Info











Click Next to fill out your Child's Medical Insurance Info

Child Medical Insurance Info


Your carrier will be billed for medical charges in the case of illness or injury while your son or daughter is involved in a church-related activity.

If your children have different insurance coverage, separate medical insurance info must be submitted for each child.

Liability Release

I (we), being at least 18 years of age or older, do for myself/ourselves (and for or on behalf of my child participant, if such child is not 18 years of age or older) hereby release, forever discharge and agree to hold harmless Coppell Bible, as well as its pastors, elders, employees, and volunteers from any and all liability, claims or demands for personal injury, sickness or death, as well as property damages and expenses, of any nature whatsoever which may be incurred by me/us and/or the child participant that occur while participating in any church trip or activity. Furthermore, I (and for or on behalf of my child participant) hereby assume all risk of personal injury, sickness, death, damage and expense as a result of participation in such trip or activity. I further agree to hold harmless and indemnify Coppell Bible, its pastors, elders, employees and volunteers for any liability sustained as the result of negligent, willful or intentional acts of any participant, including expenses incurred attendant thereto.

(If the participant has not attained the age of 18 years):
I (we) are the parent(s) or legal guardian(s) of this participant, and hereby grant my (our) permission for him/her to participate fully in church events and hereby give my (our) permission to take said participant to a doctor or hospital and hereby authorize medical treatment, including but not limited to emergency surgery or medical treatment, and assume the responsibility of all medical bills, if any. Further, should it become necessary for the participant to return home due to medical reasons, disciplinary action or otherwise, I (we) hereby assume all transportation costs.


Parent/Guardian Name of Signature Above

Click Next for our Photo Waiver

Photo Waiver

I hereby authorize Coppell Bible, hereafter referred to as “CB,” the right to publish photographs or videos taken of the minor child or children listed on this form, and their likenesses, for use in the CB's print, online and video-based marketing materials, as well as other CB publications.

I hereby release and hold harmless CB from any reasonable expectation of privacy or confidentiality for the minor child or children associated with the images specified above. Further, I attest that I am the parent or legal guardian of the child or children and that I have full authority to consent and authorize CB to use their likenesses.

I further acknowledge that participation is voluntary and that neither I or the minor child will receive financial compensation of any type associated with the taking or publication of these photographs or participation in CB marketing materials or other CB publications. I acknowledge and agree that publication of said photos confers no rights of ownership or royalties whatsoever.

I hereby release CB, its contractors, its employees, its volunteers and any third parties involved in the creation or publication of CB publications, from liability for any claims by me or any third party in connection with my participation or the participation of the minor child listed on this form.


Parent/Guardian Name of Signature Above
Submit