I understand there are many risks and do hereby release Saint Matthew Lutheran Church (SMLC), or any of it’s representatives, from any liability for accidents or injury sustained by myself which could take place during the period this authorization is in force.

        I authorize and consent to any x-ray examination, medical or surgical diagnosis, treatment and emergency hospital care which is deemed advisable by and is to be rendered under the general or specific supervision of any member of the medical staff and emergency room staff licensed under the provisions of the Medical Practice Act and on the staff of any acute general hospital holding a current license to operate a hospital from the State of California Department of Health Services.  It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care being required, but is given to provide authority and power to render care, which the aforementioned physician in the exercise of his/her best judgment may deem advisable.  The undersigned also assumes the primary responsibility for any costs connected with such treatment, understanding that SMLC’s insurance coverage will be secondary to their own insurance coverage.

        I also give permission for my image to be used in any SMLC, promotional material, SMLC web site and/or slide shows.

        This release form is completed and signed of my own free will with the purpose of authorizing medical treatment under any emergency circumstances and releasing liability specifically as stated above.