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TODAY'S DATE: July 3, 2020

CROSSROADS GRACE COMMUNITY CHURCH MEDICAL AND LIABILITY RELEASE

Crossroads Grace Community Church - Night to Shine, Turkey Bowl, 2nd SATURDAY/Citrus Saturday/Love Manteca
Crossroads Student Ministry, Crossroads Childrens Ministry, Manteca Unified School District Staff and Students

Participation, Release, Waiver & Indemnity Agreement

While Crossroads Grace Community Church makes every effort to provide a safe place for all participants, we do require that this participation agreement be read, filled out, signed and dated by the participant, parent or legal guardian of each person under the age of 18 (and every person 18 or older) who wishes to participate in any activities with Crossroads Grace Community Church.

I, the undersigned, give permission for my son or daughter to participate in the activities that occur with Crossroads Grace Community Church, including, but not limited to, travel in vehicles, community service projects on/near roads and traffic, and gardening and power equipment, dirt fields, yards, rivers, water, etc. I grant this permission with full knowledge that I accept full responsibility for any injury or accident that may occur.

Although Crossroads Grace Community Church may take reasonable steps to provide equipment and skilled members so you or your child can participate in activities for which you or your child may not be skilled in, we now remind you that these activities are not without risk. Certain risks cannot be eliminated without destroying the unique character of those activities. The same elements that contribute to the character of these activities can be cause of loss or damage to your property, accidental injury or illness or, in extreme cases, permanent trauma or death.

I, on behalf of myself, my children, my assigns and my estate, agree to release and hold harmless Crossroads Grace Community Church, Inc., its officers, Boards, agents or employees, businesses, partnerships, private or public landowners, homeowners, and the City of Manteca and Manteca Unified School District for any and all claims for injuries, causes of action, or liability related to myself or my childs participation in any activity occurring with Crossroads Grace Community Church, or on or beyond Crossroads Grace Community Church. This release does not apply to intentional and/or willful acts of misconduct by Crossroads Grace Community Church or any of its employees.

Should Crossroads Grace Community Church, or anyone acting on their behalf, or their own behalf, be required to incur attorneys fees and costs to enforce this agreement, I agree to indemnify and hold Crossroads Grace Community Church harmless for all such fees and costs.

By signing this document, I acknowledge that if anyone is hurt or property damaged during my or my childs participation in activities, I and/or my child may be found by a court of law to have waived any right to maintain a lawsuit against Crossroads Grace Community Church, the City of Manteca, any property owners, their employees, lessees, etc. at the location where I or my child might perform community services, on the basis of any claim which has been released herein.

For promotional or communication purposes, Crossroads Community Church reserves the right to use any audio, video, and/or photography of persons participating in Crossroads Grace Community Church events.

I have had sufficient opportunity to read this entire document. I have read and understood it, and agree to be bound by its terms.

I Agree

CROSSROADS GRACE COMMUNITY CHURCH 1505 MOFFAT BLVD. MANTECA, CA 95336 (209) 239-5566 Fax (209) 239-5012

First Participant's Name

First Name*

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

Home Phone:

Cell Phone:

Emergency Contact Information


Name:

Home Phone:

Cell Phone:

Allergies *

Any health conditions that could limit you from participation *
First Participant's Signature*
Second Participant's Name

First Name*

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

Home Phone:

Cell Phone:

Emergency Contact Information


Name:

Home Phone:

Cell Phone:

Allergies *

Any health conditions that could limit you from participation *
Third Participant's Name

First Name*

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

Home Phone:

Cell Phone:

Emergency Contact Information


Name:

Home Phone:

Cell Phone:

Allergies *

Any health conditions that could limit you from participation *
Fourth Participant's Name

First Name*

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

Home Phone:

Cell Phone:

Emergency Contact Information


Name:

Home Phone:

Cell Phone:

Allergies *

Any health conditions that could limit you from participation *
Fifth Participant's Name

First Name*

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

Home Phone:

Cell Phone:

Emergency Contact Information


Name:

Home Phone:

Cell Phone:

Allergies *

Any health conditions that could limit you from participation *
Sixth Participant's Name

First Name*

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

Home Phone:

Cell Phone:

Emergency Contact Information


Name:

Home Phone:

Cell Phone:

Allergies *

Any health conditions that could limit you from participation *
Seventh Participant's Name

First Name*

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

Home Phone:

Cell Phone:

Emergency Contact Information


Name:

Home Phone:

Cell Phone:

Allergies *

Any health conditions that could limit you from participation *
Eighth Participant's Name

First Name*

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

Home Phone:

Cell Phone:

Emergency Contact Information


Name:

Home Phone:

Cell Phone:

Allergies *

Any health conditions that could limit you from participation *
Ninth Participant's Name

First Name*

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

Home Phone:

Cell Phone:

Emergency Contact Information


Name:

Home Phone:

Cell Phone:

Allergies *

Any health conditions that could limit you from participation *
Tenth Participant's Name

First Name*

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

Home Phone:

Cell Phone:

Emergency Contact Information


Name:

Home Phone:

Cell Phone:

Allergies *

Any health conditions that could limit you from participation *
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*
Medical Information

If you have specific health history issues, please describe and give details of how to assist you with proper medical service in a similar instance occurs while you are with us:
Do you have Health Insurance?*

Insurance Company Name:

Your Insurance Policy Number:

Your medical insurance carrier will be billed for medical charges due to illness or injury while you are involved with Crossroads Grace Community Church. 

MEDICAL RELEASE:

In the event an emergency contact person, parent or legal guardian cannot be reached in an emergency while you are with us, or while you may be unable to speak for yourself and your emergency contact person cannot be reached, I hereby give my permission to public emergency personnel to hospitalize, to secure proper treatment and/or order an injection, anesthesia, or surgery for me as deemed necessary. The signature below is intended to serve as a medical release for my child or myself.

I Agree
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*
Parent or Guardian's Information

Home Phone:

Cell Phone:

Emergency Contact Information


Name:

Home Phone:

Cell Phone:

Allergies *

Any health conditions that could limit you from participation *
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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