Loading...

Faceplant Ministries Waiver and Release of Liability and Consent to Medical/Dental Treatment Form

In consideration of allowing my child to participate in Faceplant Ministries activities and events (hereinafter "FPM"), I acknowledge, understand and agree that:

1) The risk of injury from the activities involved in this program is significant, including the potential for permanent disability or death, and while particular rules, equipment, and personal discipline may reduce this risk, the risk of serious injury does exist; and,

2) I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASES (named in #5 below) or others, and assume full responsibility for my child's participation and for his/her wearing a helmet; and,

3) If, during my presence or my child's activity at FPM, I or my child observe any unusual significant hazard, I or they, will immediately remove my child from participation and bring such hazard to the attention of the nearest FPM staff person; and,

4) I give my consent and permission for FPM staff to obtain any emergency medical/dental treatment for my child at any hospital in case of sickness, accident or injury and to secure such medical/dental attention at my expense whether or not my insurance applies; and,

5) I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE, INDEMNIFY AND HOLD HARMLESS Faceplant Ministries, its officers, agents, employees, volunteers, other participants, and its landlord (the "RELEASES"), WITH RESPECT TO ANY AND ALL INJURY (PHYSICAL OR MENTAL), DISABILITY, DEATH, or loss or damage to person or property, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASES OR OTHERWISE, to the fullest extent permitted by law.

6) I HOLD HARMLESS and give permission for FPM staff and volunteers to transport my child to other events, pick them up, take them home (or where they are staying) and other skate spots. I agree to hold FPM and all participating staff and volunteers harmless of all medical or dental responsibilities, on and off property, overnight stays, and during transportation. 

7) Any DELIBERATE OR ACCIDENTAL damage caused to vehicles, the property or neighboring properties will be charged to the Participant or Participants Legal Guardian.

8) Photos or videos of Participants may be used for Social Media and/or Marketing purposes.

I AM THE PARENT OR LEGAL GUARDIAN OF THE ABOVE NAMED MINOR AND HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT.

I FULLY UNDERSTAND ITS TERMS, AND HAVE EXPLAINED THE "PARTICIPANT UNDERSTANDING AND ASSUMPTION OF RISK" BELOW TO MY CHILD. I UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.

First Participant Name

First Name*

Middle Name

Last Name*
First Participant Age Acknowledgment*
First Participant Date of Birth*
I certify that I am 18 years of age or older
First Participant Signature*
Second Participant Name

First Name*

Middle Name

Last Name*
Second Participant Date of Birth*
Second Participant Signature*
Third Participant Name

First Name*

Middle Name

Last Name*
Third Participant Date of Birth*
Third Participant Signature*
Fourth Participant Name

First Name*

Middle Name

Last Name*
Fourth Participant Date of Birth*
Fourth Participant Signature*
Fifth Participant Name

First Name*

Middle Name

Last Name*
Fifth Participant Date of Birth*
Fifth Participant Signature*
Sixth Participant Name

First Name*

Middle Name

Last Name*
Sixth Participant Date of Birth*
Sixth Participant Signature*
Seventh Participant Name

First Name*

Middle Name

Last Name*
Seventh Participant Date of Birth*
Seventh Participant Signature*
Eighth Participant Name

First Name*

Middle Name

Last Name*
Eighth Participant Date of Birth*
Eighth Participant Signature*
Ninth Participant Name

First Name*

Middle Name

Last Name*
Ninth Participant Date of Birth*
Ninth Participant Signature*
Tenth Participant Name

First Name*

Middle Name

Last Name*
Tenth Participant Date of Birth*
Tenth Participant Signature*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*

Emergency Contact's Relation to Participant
Insurance

Insurance Carrier*

Insurance Policy Number*
Parent or Guardian's Driver's License / ID Card

Driver's License / ID Card Number*

Issuing State*
Participant Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Relationship*

Phone*
Parent or Guardian's Age Acknowledgment*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


One or more problems exist. Please scroll up.




Powered by  Smartwaiver - TRY IT FREE!