Skatechurch Waiver And Release Of Liability And Consent To Medical Dental Treatment Form printable pdf download

MINOR

Skatechurch Waiver and Release of Liability

and Consent to Medical/Dental Treatment Form

Participant’s

Partic.

Last Name ______________________________________ First _________________________ M. I. _____ Phone__________________________

Address __________________________________________________ City _______________________ State _______ Zip _________________

Birth

Does Participant

Yes

____ /____ /____

Age ____ Grade ____

Date

have medical ins.?

Insurance Co. _________________________ Policy # ____________________

Any Portland Hospital

Insurance

applies at:

_______________________________

____________________________________________________

_________________________________________

____________________________

Specified Portland Hospital

Emergency Contact

Phone

Relationship

In consideration of allowing my child to participate in Skatechurch Inc activities and events (hereinafter “Sk8”), I acknowledge, under-

stand and agree that:

1) The risk of injury from the activities involved in this program is significant, including the potential for permanent disability or death, and

while particular rules, equipment, and personal discipline may reduce this risk, the risk of serious injury does exist; and,

2) I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES

(named in # 5 below) or others, and assume full responsibility for my child’s participation and for his/her wearing a helmet; and,

3) If, during my presence at Sk8, I observe any unusual significant hazard, I will immediately remove my child from participation and bring

such hazard to the attention of the nearest Sk8 staff person; and,

4) I give my consent and permission for Sk8 staff to obtain any emergency medical/dental treatment for my child at any hospital in case of

sickness, accident or injury and to secure such medical/dental attention at my expense whether or not my insurance applies; and,

5) I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE, INDEMNIFY AND HOLD

HARMLESS Skatechurch Inc., its officers, agents, employees, volunteers, other participants, and its landlord Central Bible Church, and its

officers, agents, employees, volunteers (the “RELEASEES”), WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH, or loss or damage to

person or property, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE, to the fullest extent permitted by

law.

I AM THE PARENT OR LEGAL GUARDIAN OF THE ABOVE NAMED MINOR AND HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION

OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, AND HAVE EXPLAINED THE “PARTICIPANT UNDERSTANDING AND ASSUMPTION OF

RISK” BELOW TO MY CHILD. I UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND

VOLUNTARILY WITHOUT ANY INDUCEMENT.

PARENT/LEGAL GUARDIAN SIGNATURE ________________________________________________ DATE SIGNED __________________

PRINT NAME ____________________________________________ PHONE #(’s) ______________________________________________

PARTICIPANT UNDERSTANDING AND ASSUMPTION OF RISK

I understand the seriousness of the risks involved in participating in this program, my personal responsibilities for adhering to the rules,

and accept them as a participant. I know it is my responsibility whether or not I choose to wear a helmet. I UNDERSTAND THAT I COULD

BE PERMANENTLY DISABLED OR EVEN DIE AS A RESULT OF AN INJURY WHILE PARTICIPATING IN SK8, BUT I STILL WANT TO PARTICIPATE

AND FULLY ACCEPT THE RISKS MYSELF.

MINOR PARTICIPANT SIGNATURE _______________________________________________ DATE SIGNED__________________

NOTARY PUBLIC:PLACE [SEAL] HERE

_________________________________

rev 12.03.15

NOTARY PUBLIC

SK8 STAFF ONLY:

Form/ ID Checked by: _____________

SIGNING PARENT ID

Check: (circle one)

Drivers License

DMV ID card

Passport

On __________________ before me, ________________________________________

personally appeared, _______________________________________ personally known

SIGNING PARENT ID # _________________________________________

to me _______________ or proved on the basis of satisfactory evidence to be the person

Birth Certificate

DMV ID Card

Driver License

Old Skatechurch ID

whose name is subscribed to the within instrument and acknowledge to me that he/she

MINORS AGE/ID

executed the same in his/her authorized capacity and that by his/her signature on the

Check: (circle one)

instrument, the person executed the instrument. Witness my hand and official seal.

Medical Insurance ID Card

Current School Picture ID

Passport

Skatechurch Waiver And Release Of Liability And Consent To Medical Dental Treatment Form

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