2017 Crossroads Community Church Medical & Liability Release Form

Participant Name *
Participant Name
Home Address *
Home Address
Participant Cell Phone *
Participant Cell Phone
If no cell phone, use home phone or parent/guardian cell phone.
Participant Birth Date
Participant Birth Date
As of Fall 2016
Gender *
Contact #1 or Father's/Legal Guardian's Name
Contact #1 or Father's/Legal Guardian's Name
EMERGENCY INFORMATION For minors, please fill out guardian information. For adults, please enter an emergency contact under Alternate Emergency contact.
Contact #1 Home Phone
Contact #1 Home Phone
Contact #1 Work Phone
Contact #1 Work Phone
Contact #1 Cell Phone
Contact #1 Cell Phone
Contact #2 or Mother's/Legal Guardian's Name
Contact #2 or Mother's/Legal Guardian's Name
Contact #2 Home Phone
Contact #2 Home Phone
Contact #2 Work Phone
Contact #2 Work Phone
Contact #2 Cell Phone
Contact #2 Cell Phone
ALTERNATE EMERGENCY CONTACT
ALTERNATE EMERGENCY CONTACT
If Contacts or Parents/Guardians are unavailable, call
Emergency Phone
Emergency Phone
Do you carry family medical/hospital insurance? *
HEALTH & INSURANCE INFORMATION NOTE: CCC will do everything possible to keep your health information private. Information on minors will be given to ministry leaders only on a "need to know" basis.
Name of family physician
Name of family physician
Family physician phone
Family physician phone
Name of family dentist/orthodontist
Name of family dentist/orthodontist
Family dentist/orthodontist phone
Family dentist/orthodontist phone
MAJOR MEDICAL PROBLEMS
Check all that apply
(Send with instructions in original packaging)
Date of last tentanus shot:
Date of last tentanus shot:
Please notify Crossroads Community Church (CCC) if you or your child has been exposed to a communicable disease within the three weeks prior to the outing or event. This health information is correct so far as I know, and I expressly consent to the participant's involvement in all activities and events during the 2017 calendar year (1/1/17 - 12/31/17), including, but not limited to, recreational activities, trips, camps, travel, and activities sponsored by CCC. The participant agrees to comply with all rules and policies for each activity and event. I authorize any person connected with CCC on any activity or event to administer first aid to the participant, as they deem necessary. I authorize medical and surgical care and transportation to a medical facility or hospital for treatment necessary for the participant's well being, at my expense. I authorize the supervisors of the activity to carryout any discipline deemed necessary for my child. I also agree, if necessary, that I will pay the expenses of my youth being sent home because of a disciplinary action. Pictures may be taken during the event for church use including posting on the church web site. This form, when completed, maybe photocopied. *
REQUIRED SIGNATURE *
REQUIRED SIGNATURE
By typing my name below, I verify that I am the parent or legal guardian of the minor, and I have authority to enter into this agreement on behalf of the participant, or I am the participant and I am 18 years old or older.
CROSSROADS COMMUNITY CHURCH ACKNOWLEDGMENT OF RISKS Although Crossroads Community Church (CCC) makes every effort to provide a safe environment, I understand that certain risks cannot be eliminated. I understand that participation in each activity and event involves inherent and other risks of injury and death. RELEASE, WAIVER OF LIABILITY, ASSUMPTION OF RISK AND INDEMNITY AGREEMENT In consideration for the participant being permitted to be involved in the activities and events during the 2017 calendar year, I the undersigned, AGREE TO THE FOLLOWING: I RELEASE, WAIVE and for ever discharge CCC, its Pastors, Employees, Officers, Volunteers, Board and Agents (collectively CCC) from ALL LIABILITY to me, my family, heirs, assigns, personal representatives or next of kin for ANY LOSS OR DAMAGE RESULTING FROM PHYSICAL OR MENTAL INJURY, DEATH OR PROPERTY DAMAGE arising from my or my child's participation in this CCC activity. I PROMISE NOT TO SUE CCC for any claim that is released under this Agreement. I AGREE TO INDEMNIFY, DEFEND, AND HOLD HARMLESS CCC and its Pastors, Employees, Officers, Volunteers, Board and Agent (collectively CCC) for any loss, liability, damage or costs incurred due to my or my child's participation in any CCC activity regardless if loss, liability, damage or costs arise directly or indirectly out of participation or transportation to and from the activity, whether such injury or loss arises out of the negligence of CCC, the participant, or otherwise. I ASSUME FULL RESPONSIBILITY FOR RISKS OF BODILY INJURY, DEATH OR PROPERTY DAMAGE arising from my or my child's participation in any CCC activity. I further acknowledge and accept that this Assumption of Risk and Waiver is intended to be as broad and inclusive as permitted by the laws of the state in which participation takes place and agree that if any portion of this Assumption of Risk and Waiver is deemed to be invalid, the remainder will continue in full legal force. If a dispute over this agreement or an claim for damages arises, the participant (or parent/guardian) agrees to resolve the matter through a mutually acceptable alternative dispute resolution process. If the participant (or parent guardian) and CCC cannot agree upon such a process, the dispute will be submitted to a three-member arbitration panel for resolution pursuant to the rules of the American Arbitration Association. I HAVE READ AND UNDERSTOOD this "Release, Waiver of Liability, and Indemnity Agreement" and signed it voluntarily, and agree that no oral representations, agreements, or inducements, apart from the foregoing written agreement have been made. I HAVE READ AND UNDERSTOOD THIS "RELEASE, WAIVER OF LIABILITY AND INDEMNITY AGREEMENT" AND AGREE TO IT. Should CCC, or anyone acting on their behalf, be required to incur attorneys' fees and costs to enforce this agreement, I agree to indemnify and hold CCC harmless for all such fees and costs. I HAVE READ AND UNDERSTOOD this "Release, Waiver of Liability, and Indemnity Agreement" and signed it voluntarily, and agree that no oral representations, agreements, or inducements, apart from the foregoing written agreement have been made. I HAVE READ AND UNDERSTOOD THIS "RELEASE, WAIVER OF LIABILITY AND INDEMNITY AGREEMENT" AND AGREE TO IT. Should CCC, or anyone acting on their behalf, be required to incur attorneys' fees and costs to enforce this agreement, I agree to indemnify and hold CCC harmless for all such fees and costs. This agreement is binding upon the participant's heirs, executors, administrators, and assigns. I acknowledge this agreement is governed by the applicable laws of the State of California. If any provision of this agreement is held in whole or in part to be unenforceable for any reason,the remainder of that provision and of the entire agreement will be severable and remain in effect. I HAVE READ, UNDERSTAND, AND VOLUNTARILY AGREE TO THIS LIABILITY RELEASE, MEDICAL RELEASE, WAIVER, CONSENT AND RELEASE OF LIABILITY, THE DISCLAIMER, ASSUMPTION OF RISK AND WAIVER AND ACKNOWLEDGEMENT AND CONSENT AGREEMENTS, FULLY UNDERSTAND THE TERMS OF EACH, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY MY SIGNING THIS FORM AND AGREEING TO THESE TERMS, AND I SIGN THIS FORM AND AGREE TO THESE TERMS FREELY AND VOLUNTARILY AND WITHOUT INDUCEMENT OF ANY KIND. FUTHER MORE, I AGREE TO INFORM CROSSROADS COMMUNITY CHURCH IN A TIMELY MANNER IF ANYTHING ON THIS FORM OR ITS ATTACHMENTS CHANGES. *
REQUIRED SIGNATURE *
REQUIRED SIGNATURE
By typing my name below, I verify that I am the parent or legal guardian of the minor, and I have authority to enter into this agreement on behalf of the participant, or I am the participant and I am 18 years old or older.
By typing my name above, I verify that I am the parent or legal guardian of the minor, and I have authority to enter into this agreement on behalf of the participant, or I am the participant and I am 18 years old or older. *
Please check one.