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MEDICAL INFORMATION & LIABILITY RELEASE

33896 POWERHOUSE ROAD, AUBERRY, CA 93602

GENERAL LIABILITY RELEASE:

I acknowledge that participation in the activity described above involves risk to the participant (and to the participant’s parents or guardians, if the 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, personal injury, property damage, and financial damage.

In consideration for the opportunity to participate in the activity described above (the “activity”), the participant (or parent/guardian if the 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/guardian) 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 that is authorized by the sponsor or its agents, employees, volunteers, or any other representatives (collectively referred to 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. 

ASSUMPTION OF THE RISK AND WAIVER OF LIABILITY RELATING TO CORONAVIRUS/COVID-19:

The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. As a result, federal, state, and local governments and federal and state health agencies recommend social distancing and have, in many locations, prohibited or limited the congregation of groups of people.

Auberry Community Church has put in place preventative measures to reduce the spread of COVID-19; however, the organization cannot guarantee that you or your child(ren) will not become infected with COVID-19. Further, attending the organization or organization-related activities could increase your risk and your child(ren)’s risk of contracting COVID-19.

By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that my child(ren) and I may be exposed to or infected by COVID-19 by attending the organization or organization-related activities and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by COVID-19 at the organization or organization-related activities may result from the actions, omissions, or negligence of myself and others, including, but not limited to, organization employees, volunteers, and organization-related activity participants and their families.

I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to my child(ren) or myself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I or my child(ren) may experience or incur in connection with my child(ren)’s attendance at the organization or participation in organization-related activities (“Claims”). On my behalf, and on behalf of my children, I hereby release, covenant not to sue, discharge, and hold harmless the organization, its employees, agents, and representatives, of and from the Claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of the organization, its employees, agents, and representatives, whether a COVID-19 infection occurs before, during, or after participation in any organization-related activity.

I understand and agree that the law of the State of California will apply to this Waiver of Liability. I HAVE CAREFULLY READ AND FULLY UNDERSTAND ALL PROVISIONS OF THIS WAIVER OF LIABILITY, AND FREELY AND KNOWINGLY ASSUME THE RISK AND WAIVE MY RIGHTS CONCERNING LIABILITY AS DESCRIBED ABOVE:

MEDIA RELEASE:

I understand and authorize that I or my minor child(ren) may be photographed or filmed and used in video presentations, and printed publications-either digital (online) or paper publications. Any exception must be received in written form prior to the date of the event.

IMPORTANT INSURANCE NOTE: In the event of an injury to the attendee, it is the policy of the organization that the individuals insurance be primary and Auberry Community Church medical coverage be secondary up to a maximum of $15,000.




First Participant's Name

First Name*

Last Name*

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

MINORS ONLY: Grade level during the current school year.

STUDENTS IN GRADES K-12: What year will you graduate?

Medical Conditions/Medications *

Allergies (Please include food allergies) *
First Participant's Signature*
Second Participant's Name

First Name*

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

MINORS ONLY: Grade level during the current school year.

STUDENTS IN GRADES K-12: What year will you graduate?

Medical Conditions/Medications *

Allergies (Please include food allergies) *
Third Participant's Name

First Name*

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

MINORS ONLY: Grade level during the current school year.

STUDENTS IN GRADES K-12: What year will you graduate?

Medical Conditions/Medications *

Allergies (Please include food allergies) *
Fourth Participant's Name

First Name*

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

MINORS ONLY: Grade level during the current school year.

STUDENTS IN GRADES K-12: What year will you graduate?

Medical Conditions/Medications *

Allergies (Please include food allergies) *
Fifth Participant's Name

First Name*

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

MINORS ONLY: Grade level during the current school year.

STUDENTS IN GRADES K-12: What year will you graduate?

Medical Conditions/Medications *

Allergies (Please include food allergies) *
Sixth Participant's Name

First Name*

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

MINORS ONLY: Grade level during the current school year.

STUDENTS IN GRADES K-12: What year will you graduate?

Medical Conditions/Medications *

Allergies (Please include food allergies) *
Seventh Participant's Name

First Name*

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

MINORS ONLY: Grade level during the current school year.

STUDENTS IN GRADES K-12: What year will you graduate?

Medical Conditions/Medications *

Allergies (Please include food allergies) *
Eighth Participant's Name

First Name*

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

MINORS ONLY: Grade level during the current school year.

STUDENTS IN GRADES K-12: What year will you graduate?

Medical Conditions/Medications *

Allergies (Please include food allergies) *
Ninth Participant's Name

First Name*

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

MINORS ONLY: Grade level during the current school year.

STUDENTS IN GRADES K-12: What year will you graduate?

Medical Conditions/Medications *

Allergies (Please include food allergies) *
Tenth Participant's Name

First Name*

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

MINORS ONLY: Grade level during the current school year.

STUDENTS IN GRADES K-12: What year will you graduate?

Medical Conditions/Medications *

Allergies (Please include food allergies) *
Parent or Guardian's Email Address

Email*

Confirm Email*
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
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:*
For Minors: Other Parent/Guardian Information

First Name

Last Name

Relationship to Minor

Phone

Email Address
Is (are) participant(s) covered by personal/family medical insurance?
Click to customize question*
No
Yes

If yes, please provide insurance company provider.

If yes, please provide insurance policy number.
Additional Authorized Pick-Up Adult (MUST be 18+ & other than listed parents/guardians)

First & Last Name of Person Authorized to Pick-up your child(ren).

First & Last Name of Person Authorized to Pick-up your child(ren).
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*

Last Name*

Relationship*

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

MINORS ONLY: Grade level during the current school year.

STUDENTS IN GRADES K-12: What year will you graduate?

Medical Conditions/Medications *

Allergies (Please include food 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.


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