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Release of Liability Waiver

4710 N. Maple Ave. | Fresno, CA 93726

559.291.9116

www.campusbiblechurch.com/waiver

LIABILITY RELEASE: I acknowledge that participation in the activity described above involves risk to the participant (and to the participant’s parents or guardians, if the participant is a minor), and may result in various types of injury including, but not limited to, the following: sickness, bodily injury, death, emotional injury, personal injury, property damage, and financial damage.

In consideration for the opportunity to participate in the activity described above (the “activity”), the participant (or parent/guardian if the 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 other loss sustained during the activity or during transportation to and from the activity, as well as for any medical treatment rendered to the participant that is authorized by the sponsor or its agents, employees, volunteers, or any other representatives (collectively referred to 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. 

MEDIA RELEASE: I understand and authorize that I or my minor child(ren) may be photographed or filmed and used in video presentations, and printed publications-either digital (online) or paper publications. Any exception must be received in written form prior to the date of the event.

IMPORTANT INSURANCE NOTE: In the event of an injury to the attendee, it is the policy of the church that the individuals insurance be primary and Campus Bible Church medical coverage be secondary up to a maximum of $10,000.

First Participant's Name

First Name*

Last Name*

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

FOR MINORS ONLY: Grade in School during the 2019/20 school year.

FOR STUDENTS IN GRADES 6-12: What year will you graduate from high school?

Allergies (please include food allergies)

Last Tetnus Shot (if known)

Medications taken / medical conditions
First Participant's Signature*
Second Participant's Name

First Name*

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

FOR MINORS ONLY: Grade in School during the 2019/20 school year.

FOR STUDENTS IN GRADES 6-12: What year will you graduate from high school?

Allergies (please include food allergies)

Last Tetnus Shot (if known)

Medications taken / medical conditions
Third Participant's Name

First Name*

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

FOR MINORS ONLY: Grade in School during the 2019/20 school year.

FOR STUDENTS IN GRADES 6-12: What year will you graduate from high school?

Allergies (please include food allergies)

Last Tetnus Shot (if known)

Medications taken / medical conditions
Fourth Participant's Name

First Name*

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

FOR MINORS ONLY: Grade in School during the 2019/20 school year.

FOR STUDENTS IN GRADES 6-12: What year will you graduate from high school?

Allergies (please include food allergies)

Last Tetnus Shot (if known)

Medications taken / medical conditions
Fifth Participant's Name

First Name*

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

FOR MINORS ONLY: Grade in School during the 2019/20 school year.

FOR STUDENTS IN GRADES 6-12: What year will you graduate from high school?

Allergies (please include food allergies)

Last Tetnus Shot (if known)

Medications taken / medical conditions
Sixth Participant's Name

First Name*

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

FOR MINORS ONLY: Grade in School during the 2019/20 school year.

FOR STUDENTS IN GRADES 6-12: What year will you graduate from high school?

Allergies (please include food allergies)

Last Tetnus Shot (if known)

Medications taken / medical conditions
Seventh Participant's Name

First Name*

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

FOR MINORS ONLY: Grade in School during the 2019/20 school year.

FOR STUDENTS IN GRADES 6-12: What year will you graduate from high school?

Allergies (please include food allergies)

Last Tetnus Shot (if known)

Medications taken / medical conditions
Eighth Participant's Name

First Name*

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

FOR MINORS ONLY: Grade in School during the 2019/20 school year.

FOR STUDENTS IN GRADES 6-12: What year will you graduate from high school?

Allergies (please include food allergies)

Last Tetnus Shot (if known)

Medications taken / medical conditions
Ninth Participant's Name

First Name*

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

FOR MINORS ONLY: Grade in School during the 2019/20 school year.

FOR STUDENTS IN GRADES 6-12: What year will you graduate from high school?

Allergies (please include food allergies)

Last Tetnus Shot (if known)

Medications taken / medical conditions
Tenth Participant's Name

First Name*

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

FOR MINORS ONLY: Grade in School during the 2019/20 school year.

FOR STUDENTS IN GRADES 6-12: What year will you graduate from high school?

Allergies (please include food allergies)

Last Tetnus Shot (if known)

Medications taken / medical conditions
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*
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Insurance Information
Is (are) participant(s) covered by personal/family medical insurance?*
Yes
No

If yes, name of insurance provider

Insurance Policy or group number
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

FOR MINORS ONLY: Grade in School during the 2019/20 school year.

FOR STUDENTS IN GRADES 6-12: What year will you graduate from high school?

Allergies (please include food allergies)

Last Tetnus Shot (if known)

Medications taken / medical conditions
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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