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Refuge-Valley Ranch Baptist Church
Activity Participation Agreement 

 

Sponsor Organization: Valley Ranch Baptist Church
1501 E. Beltline Road, Coppell, Texas 75019, 972-304-8722

Activities may include events on and off VRBC premises (including out-of-state and out-of-country), travel, recreational pursuits, physical exertion and labor, interaction with various people and the general public, team-building exercises, and may last multiple days and nights (hereafter referred to as the “Activity”). The term “Sponsor” includes Valley Ranch Baptist Church, its agents, employees, volunteers and other representatives. This agreement will cover all activities for 2019 and will also be applicable for future years if no subsequent form is provided. Participant (and Participant’s parents and guardians, if Participant is a minor) agrees to keep this information current and updated with any change and/or additional information.

Participation Agreement

I acknowledge that participation in the Activity described above involves risk to the Participant (and to Participant’s parents or guardians, if Participant is a minor) and may result in various types of injury and/or damage 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 Participant (or parent/guardian if Participant is a minor) acknowledges and accepts the risks of injury and/or damage associated with participation in and transportation to and from the Activity. The Participant (or parent/guardian if Participant is a minor) 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. Further, the Participant (or parent/guardian if Participant is a minor) releases and promises to indemnify, defend, and hold harmless the 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 Participant, the Sponsor, or otherwise. I (or parent/guardian if Participant is a minor) also assume all responsibility for providing transportation from the Activity should it be necessary to leave the Activity for medical, disciplinary or any other reasons.

In the event that an emergency arises necessitating medical or surgical attention and the Participant is unable to make medical decisions, I for myself or my minor child hereby consent and give my permission to the Sponsor and any attending physicians to make such decisions and to perform such medical treatments and/or surgery on the Participant which may be necessary.

I acknowledge that I or the minor Participant may be the subject of digital, film and video photography as well as audio recordings or other documentation and hereby grant voluntarily and with full understanding VRBC and Sponsor, a license to use such data, photos, audio recordings and other documentation in publications of the Church.

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

*Participant and all parents/guardians must sign if Participant is a minor

Dated: April 25, 2019

First Participant's Name

First Name*

Last Name*

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

Medical Information:


Family Physician *

Phone Number *

List below (or write "none") any allergies, medical, physical or mental conditions. Please be complete, even if you do not currently consider any such condition significant. *

Should the participant require medical attention at any time, list any special instructions (or write "none") which the participant might require such as being allergic to penicillin, having a rare blood type, etc. Again, please be complete, even if you do not consider any such allergies or conditions significant. *

Current Immunization (give date, or write "none" or "current"): 


Tetanus *

Polio *

Medical Insurance: 

Is Sponsor authorized to approve medical treatment?*
Is Participant covered by personal/family medical insurance?*

Insurance Company Name

Group Number

ID Number

Phone Number

Address
First Participant's Signature*
Second Participant's Name

First Name*

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

Medical Information:


Family Physician *

Phone Number *

List below (or write "none") any allergies, medical, physical or mental conditions. Please be complete, even if you do not currently consider any such condition significant. *

Should the participant require medical attention at any time, list any special instructions (or write "none") which the participant might require such as being allergic to penicillin, having a rare blood type, etc. Again, please be complete, even if you do not consider any such allergies or conditions significant. *

Current Immunization (give date, or write "none" or "current"): 


Tetanus *

Polio *

Medical Insurance: 

Is Sponsor authorized to approve medical treatment?*
Is Participant covered by personal/family medical insurance?*

Insurance Company Name

Group Number

ID Number

Phone Number

Address
Third Participant's Name

First Name*

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

Medical Information:


Family Physician *

Phone Number *

List below (or write "none") any allergies, medical, physical or mental conditions. Please be complete, even if you do not currently consider any such condition significant. *

Should the participant require medical attention at any time, list any special instructions (or write "none") which the participant might require such as being allergic to penicillin, having a rare blood type, etc. Again, please be complete, even if you do not consider any such allergies or conditions significant. *

Current Immunization (give date, or write "none" or "current"): 


Tetanus *

Polio *

Medical Insurance: 

Is Sponsor authorized to approve medical treatment?*
Is Participant covered by personal/family medical insurance?*

Insurance Company Name

Group Number

ID Number

Phone Number

Address
Fourth Participant's Name

First Name*

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

Medical Information:


Family Physician *

Phone Number *

List below (or write "none") any allergies, medical, physical or mental conditions. Please be complete, even if you do not currently consider any such condition significant. *

Should the participant require medical attention at any time, list any special instructions (or write "none") which the participant might require such as being allergic to penicillin, having a rare blood type, etc. Again, please be complete, even if you do not consider any such allergies or conditions significant. *

Current Immunization (give date, or write "none" or "current"): 


Tetanus *

Polio *

Medical Insurance: 

Is Sponsor authorized to approve medical treatment?*
Is Participant covered by personal/family medical insurance?*

Insurance Company Name

Group Number

ID Number

Phone Number

Address
Fifth Participant's Name

First Name*

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

Medical Information:


Family Physician *

Phone Number *

List below (or write "none") any allergies, medical, physical or mental conditions. Please be complete, even if you do not currently consider any such condition significant. *

Should the participant require medical attention at any time, list any special instructions (or write "none") which the participant might require such as being allergic to penicillin, having a rare blood type, etc. Again, please be complete, even if you do not consider any such allergies or conditions significant. *

Current Immunization (give date, or write "none" or "current"): 


Tetanus *

Polio *

Medical Insurance: 

Is Sponsor authorized to approve medical treatment?*
Is Participant covered by personal/family medical insurance?*

Insurance Company Name

Group Number

ID Number

Phone Number

Address
Sixth Participant's Name

First Name*

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

Medical Information:


Family Physician *

Phone Number *

List below (or write "none") any allergies, medical, physical or mental conditions. Please be complete, even if you do not currently consider any such condition significant. *

Should the participant require medical attention at any time, list any special instructions (or write "none") which the participant might require such as being allergic to penicillin, having a rare blood type, etc. Again, please be complete, even if you do not consider any such allergies or conditions significant. *

Current Immunization (give date, or write "none" or "current"): 


Tetanus *

Polio *

Medical Insurance: 

Is Sponsor authorized to approve medical treatment?*
Is Participant covered by personal/family medical insurance?*

Insurance Company Name

Group Number

ID Number

Phone Number

Address
Seventh Participant's Name

First Name*

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

Medical Information:


Family Physician *

Phone Number *

List below (or write "none") any allergies, medical, physical or mental conditions. Please be complete, even if you do not currently consider any such condition significant. *

Should the participant require medical attention at any time, list any special instructions (or write "none") which the participant might require such as being allergic to penicillin, having a rare blood type, etc. Again, please be complete, even if you do not consider any such allergies or conditions significant. *

Current Immunization (give date, or write "none" or "current"): 


Tetanus *

Polio *

Medical Insurance: 

Is Sponsor authorized to approve medical treatment?*
Is Participant covered by personal/family medical insurance?*

Insurance Company Name

Group Number

ID Number

Phone Number

Address
Eighth Participant's Name

First Name*

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

Medical Information:


Family Physician *

Phone Number *

List below (or write "none") any allergies, medical, physical or mental conditions. Please be complete, even if you do not currently consider any such condition significant. *

Should the participant require medical attention at any time, list any special instructions (or write "none") which the participant might require such as being allergic to penicillin, having a rare blood type, etc. Again, please be complete, even if you do not consider any such allergies or conditions significant. *

Current Immunization (give date, or write "none" or "current"): 


Tetanus *

Polio *

Medical Insurance: 

Is Sponsor authorized to approve medical treatment?*
Is Participant covered by personal/family medical insurance?*

Insurance Company Name

Group Number

ID Number

Phone Number

Address
Ninth Participant's Name

First Name*

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

Medical Information:


Family Physician *

Phone Number *

List below (or write "none") any allergies, medical, physical or mental conditions. Please be complete, even if you do not currently consider any such condition significant. *

Should the participant require medical attention at any time, list any special instructions (or write "none") which the participant might require such as being allergic to penicillin, having a rare blood type, etc. Again, please be complete, even if you do not consider any such allergies or conditions significant. *

Current Immunization (give date, or write "none" or "current"): 


Tetanus *

Polio *

Medical Insurance: 

Is Sponsor authorized to approve medical treatment?*
Is Participant covered by personal/family medical insurance?*

Insurance Company Name

Group Number

ID Number

Phone Number

Address
Tenth Participant's Name

First Name*

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

Medical Information:


Family Physician *

Phone Number *

List below (or write "none") any allergies, medical, physical or mental conditions. Please be complete, even if you do not currently consider any such condition significant. *

Should the participant require medical attention at any time, list any special instructions (or write "none") which the participant might require such as being allergic to penicillin, having a rare blood type, etc. Again, please be complete, even if you do not consider any such allergies or conditions significant. *

Current Immunization (give date, or write "none" or "current"): 


Tetanus *

Polio *

Medical Insurance: 

Is Sponsor authorized to approve medical treatment?*
Is Participant covered by personal/family medical insurance?*

Insurance Company Name

Group Number

ID Number

Phone Number

Address
Parent or Guardian's Email Address

Email
A signed copy of this waiver will be sent to the email address you provide.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 21 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*

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

Medical Information:


Family Physician *

Phone Number *

List below (or write "none") any allergies, medical, physical or mental conditions. Please be complete, even if you do not currently consider any such condition significant. *

Should the participant require medical attention at any time, list any special instructions (or write "none") which the participant might require such as being allergic to penicillin, having a rare blood type, etc. Again, please be complete, even if you do not consider any such allergies or conditions significant. *

Current Immunization (give date, or write "none" or "current"): 


Tetanus *

Polio *

Medical Insurance: 

Is Sponsor authorized to approve medical treatment?*
Is Participant covered by personal/family medical insurance?*

Insurance Company Name

Group Number

ID Number

Phone Number

Address
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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