Loading...

 

Unexpected Women's  Retreat

October 12-14, 2018

Oregon Garden Resort

I hereby consent to participate in programs, activities, or games offered at the above named location and dates sponserd by Summit View Church. I hereby agree that I waive and release all rights and claims that I may have at any time against Summit View Church or its representatives, whether paid or volunteer, from any injury or damages in connection with Summit View Church programs and activities. The undersigned shall indemnify and hold harmless the staff, volunteers and members of Summit View Church against any and all damage and/or expense which it may incur as the result of any claim or lawsuit instituted on behalf of the undersigned. The undersigned states that she is in good health and in proper physical condition to participate in activities held at Summit View Church or hosted by Summit View Church at another location.

MEDICAL RELEASE: In the event of an emergency, I hereby authorize an adult leader of the activity, as an agent for me, to consent to any x-ray examination; medical, dental, anesthetic or surgical diagnosis; treatments; and hospital care advised and supervised by a licensed physician, surgeon or dentist (as appropriate) licensed to practice under the laws of the state where the services are to be rendered, either at the physicians office or in a hospital. I further promise to hold harmless Summit View Church and/or its employees, agents and volunteers from any and all expense incurred pursuant to this authorization in obtaining medical treatment and/or transfer, including but not limited to: ambulance expense, cost of paramedics, hospital expense and/or physician charges.

MEDIA RELEASE: I also agree that participation grants Summit View Church and its agents the right to take and utilize photographs without any legal or financial obligation.

I expressly agree that this Release and Waiver is intended to be as broad and inclusive as permitted by the laws of the State of Washington and I agree that in the event that any provision of this Release and Waiver shall be held to be invalid by any court of competent jurisdiction, the invalidity of such clause or provision shall not otherwise affect the remaining provisions of this Release and Waiver which shall continue to be enforceable.

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 Summit View 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*
I certify that I am 18 years of age or older
First Participant's Information

Any medical conditions or allergies?
First Participant's Signature*
Second Participant's Name

First Name*

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

Any medical conditions or allergies?
Third Participant's Name

First Name*

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

Any medical conditions or allergies?
Fourth Participant's Name

First Name*

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

Any medical conditions or allergies?
Fifth Participant's Name

First Name*

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

Any medical conditions or allergies?
Sixth Participant's Name

First Name*

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

Any medical conditions or allergies?
Seventh Participant's Name

First Name*

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

Any medical conditions or allergies?
Eighth Participant's Name

First Name*

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

Any medical conditions or allergies?
Ninth Participant's Name

First Name*

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

Any medical conditions or allergies?
Tenth Participant's Name

First Name*

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

Any medical conditions or allergies?
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*
I'd like to receive emails about upcoming events at Summit View Church
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Insurance

Insurance Carrier*

Insurance Policy 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*
I certify that I am 18 years of age or older
Parent or Guardian's Information

Any medical conditions or allergies?
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