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Medical Release/Consent Form

Centerpoint Church
24470 Washington Ave. Murrieta CA 92562

951.696.1002

 

BARF All Night

 

I give permission for my child to attend the BARF All Night event November 20th 7pm- November 21st 7am, 2018.

I acknowledge that participation in the activity described above involves risk to the participant (and to the Participants parents or guardians, if participant is a minor), and may result in various types of injury including, property damage and financial damage.

In consideration for the opportunity to participate in the activity described above (the Activity), the participant (par parent/guardian if participant is a minor) acknowledges and accepts the risks of injury associated with participation in and transportation to and from the activity. The participant (or parent/guardian) accepts personal financial responsibility for any injury or another loss sustained during the activity or during the transportation to and from the activity, as well as for any medial treatment rendered to the participant that is authorized by the sport or its agents, employees, volunteers, or any other representative (collectively referred to hereinafter as the Activity Sponsor). Further the participant (or parent/guardian) releases and promises to indemnify, defend, and hold harmless the activity sponsor for any injury arising directly or indirectly out of the described activity or transportation to and from the activity whether such injury arises out of the negligence of the activity sponsor, the participant, or otherwise.

If a dispute over this agreement or any claim for damages arises, the participant (or parent/guardian) agrees to resolve the matter through mutually acceptable alternative dispute resolution process. If the participant (or parent/guardian) and the activity sponsor 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.

 

As the Parent/Guardian of
AdultMinor
Continue
First Child's Name

First Name*

Middle Name

Last Name*

Phone*
First Child's Date of Birth*
First Child's Signature*
Parent or Guardian's Email Address

Email*

Confirm Email*
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Insurance

Insurance Carrier*

Insurance Policy Number*
Phone Numbers

Primary Cell Number *

Secondary Phone Number
Special Health Needs/Allergies/Medications
Basic pain killers for headaches, fevers, allergies, colds and coughs:
Tylenol
Advil
Antihistamines
Cough/Cold

Allergies or special instructions
Medical Treatment Authorization
Is sponsor authorized to approve medical treatment?*
Yes
No
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.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
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.


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