Loading...

CIY MIX will be from July 27-29 (coming back late on the 29th) at High Hill Camp in Missouri. Students will be transported by vans. 

Trip Coordinator: Garrett LeVault

Hope Church Address: 3000 Lenhart Road | Springfield, IL 62711
Hope Church Phone Number: 217-787-1446

READ CAREFULLY
In consideration for the opportunity to participate in the activity described above (the “Activity”), the Participant (or parent/guardian if Participant is a minor) acknowledges and accepts the risks of injury associated with participation in and transportation to and from the activity. The Participant (or parent or guardian) accepts 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 that is authorized by the Sponsor or its agents, employees, volunteers, or any other representatives (collectively referred to hereinafter as the “Activity Sponsor”).

Further, the Participant (or parent/guardian) releases and promises to indemnify, defend, and hold harmless the Activity 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 Activity Sponsor, the Participant, or otherwise.

I certify that I am (or my child is) physically fit for participation in this activity, and have not been advised to not participate by a qualified medical professional. I certify that there are no health-related reason or problems which preclude my (or my child's) participation in this activity.

I fully understand and 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 including, but not limited to, the following; sickness, bodily injury, death, emotional injury, property damage and financial damage.

I agree to indemnify Sponsor against any and all claims, actions lawsuits, damages and judgements, including attorney’s fees, arising out of or relating to my participation in the Activity.

This Release for Participation in Activity (“Release”) shall not be in any way construed as an admission by the Sponsor that it has acted wrongfully with respect to me or any other person, that it admits liability or responsibility at any time for any purpose, or that I have any rights whatsoever against the Sponsor.

I specifically understand that I am releasing, discharging and waiving any claims or actions that I may have presently or in the future for the negligent acts or other conduct by the owners, agents, officers or employees of the Sponsor. This waiver and release is good through August 1, 2022.

This Release shall be binding upon the parties and their respective heirs, administrators, personal representatives, executors, successors and assigns. I have the authority to release the Claims and have not assigned or transferred any Claims to any other party. The provisions of this Release are severable. If any provision is held to be invalid or unenforceable, it shall not affect the validity or enforceability of any other provision. This Release constitutes the entire agreement between the parties and supersedes any prior oral or written agreements or understandings between the parties concerning the subject matter of this Release. This Release may not be altered, amended or modified, except by a written document signed by both parties. The terms of this Release shall be governed by and construed in accordance with the laws of the State of Illinois.

I HAVE CAREFULLY READ AND FULLY UNDERSTAND ALL PROVISIONS OF THE ABOVE PARTICIPATION AGREEMENT AND AM FREELY, KNOWINGLY AND VOLUNARILTY ENTERING INTO THE AGREEMENT.

IF APPLICABLE, ALL PARTICIPANTS OR SPECTATORS AT ACTIVITY MUST COMPLETE A SAFETY ORIENTATION BEFORE PARTICIPATING. IF YOU CANNOT FOLLOW THE RULES YOU ARE NOT ALLOWED TO PARTICIPATE THAT DAY OR ALLOWED IN PARTICIPATION AREAS.


 

First Participant's Name

First Name*

Middle Name

Last Name*

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

Name of Emergency Contact

Phone Number for Emergency Contact

List of Student's Allergies and Medical Conditions
Is sponsor authorized to approve medical treatment?*
Yes
No
Is participant covered by personal/family medical insurance?*
Yes
No

If yes, name of insurer

Policy or group number

Preferred Hospital
First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

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

Name of Emergency Contact

Phone Number for Emergency Contact

List of Student's Allergies and Medical Conditions
Is sponsor authorized to approve medical treatment?*
Yes
No
Is participant covered by personal/family medical insurance?*
Yes
No

If yes, name of insurer

Policy or group number

Preferred Hospital
Third Participant's Name

First Name*

Middle Name

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

Name of Emergency Contact

Phone Number for Emergency Contact

List of Student's Allergies and Medical Conditions
Is sponsor authorized to approve medical treatment?*
Yes
No
Is participant covered by personal/family medical insurance?*
Yes
No

If yes, name of insurer

Policy or group number

Preferred Hospital
Fourth Participant's Name

First Name*

Middle Name

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

Name of Emergency Contact

Phone Number for Emergency Contact

List of Student's Allergies and Medical Conditions
Is sponsor authorized to approve medical treatment?*
Yes
No
Is participant covered by personal/family medical insurance?*
Yes
No

If yes, name of insurer

Policy or group number

Preferred Hospital
Fifth Participant's Name

First Name*

Middle Name

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

Name of Emergency Contact

Phone Number for Emergency Contact

List of Student's Allergies and Medical Conditions
Is sponsor authorized to approve medical treatment?*
Yes
No
Is participant covered by personal/family medical insurance?*
Yes
No

If yes, name of insurer

Policy or group number

Preferred Hospital
Sixth Participant's Name

First Name*

Middle Name

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

Name of Emergency Contact

Phone Number for Emergency Contact

List of Student's Allergies and Medical Conditions
Is sponsor authorized to approve medical treatment?*
Yes
No
Is participant covered by personal/family medical insurance?*
Yes
No

If yes, name of insurer

Policy or group number

Preferred Hospital
Seventh Participant's Name

First Name*

Middle Name

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

Name of Emergency Contact

Phone Number for Emergency Contact

List of Student's Allergies and Medical Conditions
Is sponsor authorized to approve medical treatment?*
Yes
No
Is participant covered by personal/family medical insurance?*
Yes
No

If yes, name of insurer

Policy or group number

Preferred Hospital
Eighth Participant's Name

First Name*

Middle Name

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

Name of Emergency Contact

Phone Number for Emergency Contact

List of Student's Allergies and Medical Conditions
Is sponsor authorized to approve medical treatment?*
Yes
No
Is participant covered by personal/family medical insurance?*
Yes
No

If yes, name of insurer

Policy or group number

Preferred Hospital
Ninth Participant's Name

First Name*

Middle Name

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

Name of Emergency Contact

Phone Number for Emergency Contact

List of Student's Allergies and Medical Conditions
Is sponsor authorized to approve medical treatment?*
Yes
No
Is participant covered by personal/family medical insurance?*
Yes
No

If yes, name of insurer

Policy or group number

Preferred Hospital
Tenth Participant's Name

First Name*

Middle Name

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

Name of Emergency Contact

Phone Number for Emergency Contact

List of Student's Allergies and Medical Conditions
Is sponsor authorized to approve medical treatment?*
Yes
No
Is participant covered by personal/family medical insurance?*
Yes
No

If yes, name of insurer

Policy or group number

Preferred Hospital
Parent or Guardian's Email Address

Email*

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


By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

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

Name of Emergency Contact

Phone Number for Emergency Contact

List of Student's Allergies and Medical Conditions
Is sponsor authorized to approve medical treatment?*
Yes
No
Is participant covered by personal/family medical insurance?*
Yes
No

If yes, name of insurer

Policy or group number

Preferred Hospital
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 - TRY IT FREE!