Ekklesia Youth Summer Kickoff

Participant Name

Participant Age

Allergies/Food restrictions

Guardian Name

Guardian Email

This address will receive a confirmation email

Guardian Phone

Guardian Address

Medical Information

Family Physician

Physician Phone

Health Insurance Company

Health ID Number

Emergency Contact

Emergency Contact Name

Emergency Contact Phone

Relation to Participant

AUTHORIZATION TO CONSENT TO MEDICAL TREATMENT OF MINOR CHILD: In the event that a serious accident or illness befalls your child, Ekklesia Church will first make every effort to contact you at home or place of business to comply with your instructions. If you cannot be located, Ekklesia Church is authorized to: 1. Contact the family physician or alternative names listed above and follow their instructions. 2. Transport the above child to a local hospital for treatment by emergency room physician on duty. 3. The undersigned hereby authorize physician named to give consent for any procedure or hospital care deemed advisable by said doctor. In the event that the doctor is not available, Ekklesia’s leadership is authorized to give necessary consent for any treatment, care, diagnosis, and/or examination of the person named. I hereby release Ekklesia Church, its’ employees and agents from all liability whatsoever for any injury, damage, or loss which may be sustained by my child during the course of involvement with Ekklesia Church.

Guardian Name

Date Signed

WAIVER OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT

Waiver: In consideration of myself or my child being permitted to participate in any way at the Ekklesia Youth Summer Kickoff on June 19, 2024, I for myself, my heirs, personal representatives, or assigns do hereby release, waive, discharge, and/or covenant not to sue Ekklesia Eugene, its officers, employees, and agents from liability from any and all claims resulting in personal injury, accident, or illness (including death), and property loss arising from, but not limited to, participation at the Ekklesia Youth Summer Kickoff.

Assumption of Risks: Participation at the Ekklesia Youth Summer Kickoff carries with it certain inherent risks that cannot be eliminated regardless of the care taken to avoid injuries. Specific risks vary from one activity to another but the risks range from minor injuries such as scratches, bruises, and sprains, to major injuries such as eye loss or loss of sight, joint or back injuries, heart attacks, and/or concussions, to catastrophic injuries including paralysis and/or death.

I have read the previous paragraphs and I know, understand, and appreciate these and other risks that are inherent in participation at the Ekklesia Youth Summer Kickoff. I hereby assert that my or my child’s participation is voluntary and I knowingly assume all risks.

Indemnification and hold harmless: I also agree to indemnify and hold harmless Ekklesia Eugene for any and all claims, actions, suits, procedure costs, expenses, damages, and liabilities including attorneys’ fees, brought as a result of my participation at the Ekklesia Youth Summer Kickoff, and to reimburse them for any such cost incurred.

Severability: The undersigned further expressively agrees that this Waiver of Liability, Assumption of Risk, and Indemnity Agreement is intended to be as broad and inclusive as permitted by the law of the state of Oregon, and if any portion is later held invalid, it is heretofore agreed that the balance shall continue to be in full force and legal effect.

Acknowledgement of Understanding: I have read this Waiver of Liability, Assumption of Risk, and Indemnity Agreement, and fully understand its terms, and understand that I am giving up substantial rights, including my right to sue. I acknowledge that I am signing the agreement freely and voluntarily and intent my signature to be complete in unconditional release of all liability to the greatest extent allowed by law.

Electronic Signature: I understand that typing my name above the "signature" line is the same as my signature on paper and I agree my electronic signature is the legal equivalent of my manual/handwritten signature on this waiver. By typing my name above the "signature" line using any device, means or action, I consent to the legally binding terms and conditions of this Agreement. I further agree that my signature on this document is as valid as if I signed the document in writing.

Electronic Signature of Parent or Guardian

Today's Date

Description

Please fill out this form and click submit.

Ekklesia Youth Summer Kickoff

Description

Please Fix the Following