Faith Assembly of God 417.623.0583
Sponsor: Telephone:
Kids Of Power:
Description of Activity:
Where: When:
Date and Location of
Activity:
Participant
Information
(To be completed by a parent or an authorized guardian)
Name of
Participant:________________________________________ Email: __________________________
Address: ________________________________________________ Telephone: ______________________
Name of Emergency contact: _________________________________________________________________
Telephone: _______________________________________________________________________________
(Day)
(Evening)
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: _____________________________________________________________________
Participation Agreement
By signing
below, the participant (or parent/guardian if participant is a minor) acknowledges and accepts the risks of physical injury associated
with participation in the activity described above. Except for gross negligence on the part of the sponsor and/or its
representatives, including employees, and/or its volunteers, the participant (or parent/guardian)
accepts personal financial responsibility for any bodily or personal injury
sustained during the activity.
Further, the participant (or parent/guardian) promises to hold harmless the sponsor (Faith Assembly of God) and
its representatives, including employees, and its volunteers, for any injury
related to the activity.
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
arbitration process.
Signature: ____________________________________________________________________ Date: __________________
(Participant or parent/guardian if
participant is a minor)
Medication:____________________________________________________________________________________________
_____________________________________________________________________________________________________
_____________________________________________________________________________________________________