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Liability Release form - Project Timothy 2021

Release of Liability

I acknowledge that I expressly agree that this release, waiver, and indemnity agreement is intended to be broad and inclusive as permitted by the laws of the State of Arizona and that, if any portion of the agreement is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.

I give permission for my student to attend the VSM Back to School Retreat hosted by Vineyard Gilbert.. I hereby release and discharge Vineyard Gilbert and their staff, leaders, or adult volunteers as well as any other staff, leaders, and volunteers for any damage, losses, or injuries to person or property that may be sustained by my student while participating in the VSM Back to School retreat. I understand that he/she is driven in a vehicle by someone other than their parent/guardian. In the event of an emergency affecting the health or welfare of the participants, sponsors, leaders, or adult chaperones have permission to administer first and and/or transport the individual to the nearest doctor or hospital for further medical attention, as deemed necessary. The individual acting in response to the emergency will be held blameless. Any medical expenses incurred will be borne by the participant or parents/guardians of the participant. I understand and agree to pay the total amount due.

I have carefully read the above release and know its contents, am aware that this is a release of liability and sign this release voluntarily. I release all officials and professional personnel from any claim whatsoever on account of first aid, treatment or service rendered to my child during the timeframe of August 27-29, 2021 while in their care.

Dated: October 24, 2021

First Participant's Name

First Name*

Last Name*
First Participant's Date of Birth*
I certify that I am 18 years of age or older
First Participant's Information
Medical Insurance:*

Medical Carrier: *

Policy Number: *
Does this child have any disabilities, handicaps, present injuries, limitations, allergies, hemophilia, heart condition, history of respiratory illness or any other significant medical condition?*

If yes, please state condition:
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information
Medical Insurance:*

Medical Carrier: *

Policy Number: *
Does this child have any disabilities, handicaps, present injuries, limitations, allergies, hemophilia, heart condition, history of respiratory illness or any other significant medical condition?*

If yes, please state condition:
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information
Medical Insurance:*

Medical Carrier: *

Policy Number: *
Does this child have any disabilities, handicaps, present injuries, limitations, allergies, hemophilia, heart condition, history of respiratory illness or any other significant medical condition?*

If yes, please state condition:
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information
Medical Insurance:*

Medical Carrier: *

Policy Number: *
Does this child have any disabilities, handicaps, present injuries, limitations, allergies, hemophilia, heart condition, history of respiratory illness or any other significant medical condition?*

If yes, please state condition:
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information
Medical Insurance:*

Medical Carrier: *

Policy Number: *
Does this child have any disabilities, handicaps, present injuries, limitations, allergies, hemophilia, heart condition, history of respiratory illness or any other significant medical condition?*

If yes, please state condition:
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information
Medical Insurance:*

Medical Carrier: *

Policy Number: *
Does this child have any disabilities, handicaps, present injuries, limitations, allergies, hemophilia, heart condition, history of respiratory illness or any other significant medical condition?*

If yes, please state condition:
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information
Medical Insurance:*

Medical Carrier: *

Policy Number: *
Does this child have any disabilities, handicaps, present injuries, limitations, allergies, hemophilia, heart condition, history of respiratory illness or any other significant medical condition?*

If yes, please state condition:
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information
Medical Insurance:*

Medical Carrier: *

Policy Number: *
Does this child have any disabilities, handicaps, present injuries, limitations, allergies, hemophilia, heart condition, history of respiratory illness or any other significant medical condition?*

If yes, please state condition:
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information
Medical Insurance:*

Medical Carrier: *

Policy Number: *
Does this child have any disabilities, handicaps, present injuries, limitations, allergies, hemophilia, heart condition, history of respiratory illness or any other significant medical condition?*

If yes, please state condition:
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information
Medical Insurance:*

Medical Carrier: *

Policy Number: *
Does this child have any disabilities, handicaps, present injuries, limitations, allergies, hemophilia, heart condition, history of respiratory illness or any other significant medical condition?*

If yes, please state condition:
Parent or Guardian's Email Address

Email*

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

In case of emergency, contact:


Doctor's Name: *

Phone Number: *

I, the undersigned parent or legal guardian of the participant, a minor, hereby authorize the Directors, Assistant Directors, and Supervisors, acting in the capacity as my agent to consent to medical, surgical or dental examination and/or treatment. In case of emergency, I hereby authorize treatment and/or care at any hospital. If there is an emergency and I cannot be reached, please contact:


Name: *

Phone Number: *

Address of Emergency Contact: *
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*
Parent or Guardian's Date of Birth*
I certify that I am 18 years of age or older
Parent or Guardian's Information
Medical Insurance:*

Medical Carrier: *

Policy Number: *
Does this child have any disabilities, handicaps, present injuries, limitations, allergies, hemophilia, heart condition, history of respiratory illness or any other significant medical condition?*

If yes, please state condition:
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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