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Countryside Bible Church Youth Group

2019-20 Annual Release Form

Today's Date: November 16, 2019

This health history is true, current and in all things correct. I hereby give my permission to a physician, nurse, or dentist selected by Countryside Bible Church (CBC) to provide medical or dental aid as required for any illness and/or injury that may occur or arise during, or incident to, any CBC event or activity. I further give my permission for CBC, including its officers, employees, agents, volunteers, members of the Board of Elders, and/or any of their designee (the Released Parties), to transport to and/or from any necessary facility the above-named participant to secure any needed medical and/or dental care. In providing this release, I understand that the Released Parties are not obligated to carry any insurance to cover any medical and/or dental expenses arising from, or incident to, the above-referenced care. If such insurance is carried, coverage will be provided only for expenses in excess of the limits of the participants insurance. I understand that my personal insurance is my primary coverage.

Consent and Release from Liability

I grant permission forhereinafter the Participant to participate in all Countryside Bible Church Youth services and for any Countryside Bible Church Youth activity from June 1, 2019 through May 31, 2020 (The Released Period). In consideration of Countryside Bible Church providing these services and activities, I do hereby release, discharge and forever waive and hold harmless Countryside Bible Church, its officers, employees, agents, volunteers, and members of the Board of Elders, and/or their designee (the Released Parties) from any and all demands, claims and/or causes of action (known or unknown), judgment or any adjudication, at law or in equity, by reason of any injury or illness (whether for death, wrongful death, personal injury (whether physical, emotional and/or psychiatric or any combination thereof), loss of consortium, or property damage, actual or alleged, that may be sustained as a result of, or incident to, any CBC service or activity that the Participant engages in, whether on CBC premises, on the way to or from these services and/or activities, or at any third-party site of any CBC service or activity. These activities include, but are not limited to, flag football, basketball, dodgeball, obstacle courses, Outpost (a physically demanding game of tag played outside at night time), Dart Wars (a Nerf gun game of tag played outdoors at night time that can be physically demanding), and swim parties. I, on behalf of the Participant, am assuming all risk arising from or incident to any CBC service or activity. And I am hereby releasing, discharging, and/or waiving on behalf of the Participant and any of the Participants heirs, assigns, relatives, and/or legal representatives. PLEASE NOTE this waiver and release is intended to include and does include your waiver of any and all acts of future negligence, including gross negligence. I HAVE READ THIS DOCUMENT. I UNDERSTAND IT IS A RELEASE AND WAIVER OF ALL CLAIMS.

This authorization shall remain effective until revoked in writing delivered to Countryside Bible Church. As such, you are releasing and waiving any and all claims for any activity or service during the Released Period. Moreover, I shall defend, indemnify and hold harmless any or all the Released Parties from any and all claims, actions, suits, procedures, costs, expenses, damages and liabilities, including reasonable attorneys fees, and will reimburse them for any such expenses incurred. I agree that this release may be pleaded as a bar to any action, suit or proceedings taken at any time against the Released Parties by me, the Participant, or anyone on behalf of the Participant. I further expressly agree that the foregoing waiver, assumption of risks, release and indemnity agreement is intended to be as broad and inclusive as is permitted by Texas law and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Signature*
Second Participant's Name

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

First Name*

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

Phone*
Parent or Guardian's Date of Birth*
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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