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121 Community Church

Authorization for Treatment, Release of Claims, and Acknowledgement of Risk

RELEASE OF CLAIMS AND ACKNOWLEDGEMENT OF RISKS

By this agreement, I voluntarily release and agree to exempt 121 Community Church (hereafter 121CC), its agents, employees, volunteers, and all other persons or entities acting in any capacity on its behalf, from any claims, demands, causes of actions, or liability for personal injury, property damage, or wrongful death which are in any way connected with my participation in any activity, observance or use of 121CC facilities or equipment, or engaging in or receiving instructions in any activities related to 121CC, including any such claims that are caused by any act of negligence. 

Authorization for Treatment, Release of Claims, and Acknowledgement of Risk

I  hereby agree as follows:

I understand that 121CC has difficult jobs to perform. They seek safety, but they are not infallible. They might not be aware of a participant’s fitness or abilities. They may give insufficient warnings or instructions, and any equipment being used might malfunction. I expressly agree and promise to accept and assume all the risks existing in activities occurring as a result of events, programs, and activities under the implementation of 121CC. My participation in any activity is purely voluntary, and my election to participate in spite of the risks, some of which may involve dangers and risk of bodily injury. I certify that I have insurance to cover injury or damage I may cause or suffer while participating, or else I agree to bear the cost of such injury or damage myself. I further certify that I have no medical or physical conditions that could interfere with my safety, or else I am willing to assume and bear the cost of all risk that may be created, directly or indirectly, by any such conditions. Furthermore, should it be necessary for me to return home for disciplinary reasons, I hereby assume responsibility for all transportation costs.

RELEASE OF CLAIMS AND AUTHORIZATION FOR TREATMENT

I, the undersigned, give consent to any x-ray, examination, anesthetic, dental or surgical diagnosis or treatment and hospital care under the general or special supervision and upon the advice of or to be rendered by a licensed physician and/or surgeon and/or dentist. I also assume personal responsibility for all medical bills and do certify that I have secured primary medical insurance. Further, should it be necessary for me to return home for medical reasons, or otherwise, I hereby assume responsibility for all transportation costs.

By signing this release and authorization, I acknowledge that if I am hurt or if any property is damaged during their participation in this activity, I may be found by a court of law to have waived my right to maintain a lawsuit against 121CC on the basis of any claim from which I have released it herein. I have had sufficient opportunity to read this entire release and authorization, and am fully aware of and understand the terms and the legal consequences of the signing of this release, and agree to be bound by its terms. The undersigned intends his/her signature to be a complete and unconditional release of all liability to the greatest extent allowed by the law and if any portion of the release and/or authorization is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. 

Dated: June 26, 2019

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information

School: *

Grade: *

MEDICAL INFORMATION 


Name of insurance company:

Name of Primary Subscriber:

Policy Number:

Phone number of insurance company:

Date of last tetanus/booster: *

Please list any medications taken on a regular basis:

Please list any medications to which you are allergic:

Please list any other allergies (food, insects, natural elements, etc.):

Please list any other special instructions:
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information

School: *

Grade: *

MEDICAL INFORMATION 


Name of insurance company:

Name of Primary Subscriber:

Policy Number:

Phone number of insurance company:

Date of last tetanus/booster: *

Please list any medications taken on a regular basis:

Please list any medications to which you are allergic:

Please list any other allergies (food, insects, natural elements, etc.):

Please list any other special instructions:
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information

School: *

Grade: *

MEDICAL INFORMATION 


Name of insurance company:

Name of Primary Subscriber:

Policy Number:

Phone number of insurance company:

Date of last tetanus/booster: *

Please list any medications taken on a regular basis:

Please list any medications to which you are allergic:

Please list any other allergies (food, insects, natural elements, etc.):

Please list any other special instructions:
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information

School: *

Grade: *

MEDICAL INFORMATION 


Name of insurance company:

Name of Primary Subscriber:

Policy Number:

Phone number of insurance company:

Date of last tetanus/booster: *

Please list any medications taken on a regular basis:

Please list any medications to which you are allergic:

Please list any other allergies (food, insects, natural elements, etc.):

Please list any other special instructions:
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information

School: *

Grade: *

MEDICAL INFORMATION 


Name of insurance company:

Name of Primary Subscriber:

Policy Number:

Phone number of insurance company:

Date of last tetanus/booster: *

Please list any medications taken on a regular basis:

Please list any medications to which you are allergic:

Please list any other allergies (food, insects, natural elements, etc.):

Please list any other special instructions:
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information

School: *

Grade: *

MEDICAL INFORMATION 


Name of insurance company:

Name of Primary Subscriber:

Policy Number:

Phone number of insurance company:

Date of last tetanus/booster: *

Please list any medications taken on a regular basis:

Please list any medications to which you are allergic:

Please list any other allergies (food, insects, natural elements, etc.):

Please list any other special instructions:
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information

School: *

Grade: *

MEDICAL INFORMATION 


Name of insurance company:

Name of Primary Subscriber:

Policy Number:

Phone number of insurance company:

Date of last tetanus/booster: *

Please list any medications taken on a regular basis:

Please list any medications to which you are allergic:

Please list any other allergies (food, insects, natural elements, etc.):

Please list any other special instructions:
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information

School: *

Grade: *

MEDICAL INFORMATION 


Name of insurance company:

Name of Primary Subscriber:

Policy Number:

Phone number of insurance company:

Date of last tetanus/booster: *

Please list any medications taken on a regular basis:

Please list any medications to which you are allergic:

Please list any other allergies (food, insects, natural elements, etc.):

Please list any other special instructions:
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information

School: *

Grade: *

MEDICAL INFORMATION 


Name of insurance company:

Name of Primary Subscriber:

Policy Number:

Phone number of insurance company:

Date of last tetanus/booster: *

Please list any medications taken on a regular basis:

Please list any medications to which you are allergic:

Please list any other allergies (food, insects, natural elements, etc.):

Please list any other special instructions:
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information

School: *

Grade: *

MEDICAL INFORMATION 


Name of insurance company:

Name of Primary Subscriber:

Policy Number:

Phone number of insurance company:

Date of last tetanus/booster: *

Please list any medications taken on a regular basis:

Please list any medications to which you are allergic:

Please list any other allergies (food, insects, natural elements, etc.):

Please list any other special instructions:
Participant's 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 or Guardian's Email Address

Email*

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

Last Name*

Relationship*

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

School: *

Grade: *

MEDICAL INFORMATION 


Name of insurance company:

Name of Primary Subscriber:

Policy Number:

Phone number of insurance company:

Date of last tetanus/booster: *

Please list any medications taken on a regular basis:

Please list any medications to which you are allergic:

Please list any other allergies (food, insects, natural elements, etc.):

Please list any other special instructions:
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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