Activity Participation Agreement

Unless otherwise indicated, please answer all questions with your personal information. If you are also the participant, then just provide your information in all areas.

Your name *

Email address *

Phone number *

Address *

Participant Name *

Participant Address *

If different from guardian's address. Please write same, if the participant lives with you full-time.

Participant Phone Number

If different from guardian's phone number.

Participant Email

If different from guardian's email.

Participant Birthdate *

Additional Parent/Guardians Name and Phone *

Please include phone numbers.

Emergency Contact Name *

Emergency Contact Phone Number *

Please provide someone other than yourself. You will be first contact and emergency contact will be who we call after you.

Participant Medical Notes *

Please list all allergies or medical conditions of participant. Please include anything that could be relevant to the activities planned.

Is Activity Sponsor authorized to approve medical treatment? *

Please see below for explanation of who Activity Sponsor is.

Is participant covered by personal/family medical insurance? *

If yes, Name of Insurer:

Participation Agreement

I 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, 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 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 hereinafter as the “Activity Sponsor”). Further, the Participant (or parent/guardian) releases and promises to indemnify, defend, and hold harmless the Activity Sponsor and/or FCC 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. If a dispute over this agreement or any claim for damages arises, the Participant (or parent/guardian) agrees to resolve the matter through a mutually acceptable alternative dispute resolution process. If the Participant (or parent/guardian) and the Activity Sponsor cannot agree upon such a process, the dispute will be submitted to a three-member arbitration panel for resolution pursuant to the rules of the American Arbitration Association.

Guardian Signature *

*I consent to any or all images made of me or my child, by whatever means, to be used for publicity and/or outreach materials for Fairlawn Community Church (FCC) in any format including video, website and print. I understand that if my image or my child's image is published on the internet then it will be accessible to users from all over the world and may be copied and used by any other person using the internet. Most importantly, I understand that once my image or my child's image has been published on the internet, FCC has no control over its subsequent use and disclosure by others. I agree to hold FCC harmless against any and all claims or damages arising out of the making, and/or use, of any images of me and/or minors under my guardianship.

Participant Signature *

*I consent to any or all images made of me, by whatever means, to be used for publicity and/or outreach materials for Fairlawn Community Church (FCC) in any format including video, website and print. I understand that if my image is published on the internet then it will be accessible to users from all over the world and may be copied and used by any other person using the internet. Most importantly, I understand that once my image has been published on the internet, FCC has no control over its subsequent use and disclosure by others. I agree to hold FCC harmless against any and all claims or damages arising out of the making, and/or use, of any images of me and/or minors under my guardianship.

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