Yukon Bible Church - Medical Release Form

Participant's Information

First Name

Last Name

Email

Address 1

Address 2

Country

City

State

Zip/Postal Code

In Case of an Emercency Notify:

Relationship to Participant

Mobile Phone Number

Other Phone Number

Medical Profile

List any medical difficulties:

List any previous medicines or substances to which you are allergic:

List any previous operations or series illnesses:

List any medications you are currently taking:

List any special diet or special needs:

Date of Tetanus Immunization

Family Physician:

Physician Phone Number

Insurance Co.

Policy #

Subscriber Name:

Subscriber Number:

Permission, Acknowledgments, Release, Indemnity

I, the undersigned Participant, (and, if Participant is a minor, I the undersigned Parent/Guardian) hereby:

A. Permission For Medical Treatment:

Grant my permission for any event director, church staffer or adult present or in charge of First Aid, to obtain medical attention in case of sickness or injury to Participant, including transporting Participant to a medical facility and sharing the above information with medical personnel, and further hereby give permission for medical personnel to administer medical care to Participant, as necessary.

D. Release and Idemnity:

Acknowledge and agree that I release and forever hold harmless the venue, church, event sponsors, trustees, directors, officers, employees, agents, and affiliates (collectively, the “Released Parties”) from any and all claims or demands for personal injury, sickness, and death, as well as property damage and expenses, of any nature whatsoever, incurred by me or my minor child while participating in the event. I also assume full personal responsibility for all medical bills for me or my minor child. I agree to indemnify the Released Parties from any and all claims and demands for personal injury or death as well as property damage and expenses of any nature whatsoever.

E. Understanding:

Represent and acknowledge that (1) I have completely read and understand this document and all its terms and all matters referred to herein, and my signature below is my voluntary, free act and deed, (2) I have had ample opportunity to obtain the advice of counsel, (3) by signing this document, I understand that I am relinquishing legal rights and remedies that may have otherwise been available to me, (4) I understand that the above Releases shall be construed as broadly and inclusively as is permitted by applicable law and agree that if any portion of this document is held invalid, the remaining shall continue in full force and effect, (5) to the extent any restriction on filing lawsuits is deemed unlawful, I agree to submit any claims to Christian conciliation/mediation organization for binding resolution, and (6) a copy of this form as signed shall be treated as authentic and binding as the original.

Complete and sign below (Participants who are minors require Parent/Legal Guardian signature).

Participant's Signature if 18 or above (Type Below / Type N/A if does not apply)

Date Signed: (N/A if does not apply)

Date of Birth: (N/A if does not apply)

Parent/Guardian Signature if below 18: (N/A if does not apply)

Phone Number: (N/A if does not apply)

Date Signed: (N/A if does not apply)