Family Focus Week- VBS Participation/Liability Agreement July 31-Aug 3, 2019
Christ's Church of Fountain Hills -15555 E. Bainbridge Ave - Fountain Hills - AZ- 85268- 480-837-3121 x 103
Scott Mathis- Kids Pastor- scott.mathis@christschurch.online
Parent/guardian Name *
Your answer
Parent/guardian phone *
Your answer
Parent/guardian Email *
Your answer
Family Address *
Your answer
Emergency Contact Name *
Your answer
Emergency Contact Phone *
Your answer
Participant 1 Name *
Your answer
Will Participant 1 attend "Late Night" *
Participant 1 Allergies? (If none=NA) *
Your answer
Participant 2 Name
Your answer
Will Participant 2 attend "Late Night"?
Participant 2 Allergies? (If none=NA)
Your answer
Participant 3 Name
Your answer
Will Participant 3 Attend "Late Night"?
Participant 3 Allergies (If none=NA)
Your answer
Participant 4 Name (If more than 4 participants please complete an additional form.)
Your answer
Will Participant 4 attend "Late Night"?
Participant 4 Allergies? (If none=NA)
Your answer
Is Sponsor (CCFH) authorized to approve medical treatment if needed? *
Are Participants covered by family medical Insurance? *
Name of Insurer
Your answer
Policy #
Your answer
Group #
Your answer
Participation Agreement: I acknowledge that participation in the activity described above involves risk to the participant(s) a minor, and may result in various types of injury including but not limited to: sickness, injury, death, emotional injury, personal injury, property damage and financial damage. In consideration for the opportunity of participation in this event, I (parent or guardian if minor(s) acknowledge and accept the personal and financial risks for any injury or other loss sustained during the activity as well as for any medical treatment rendered to the participant(s) that is authorized by the sponsor or it's agents, employees, volunteers. Further, I release and promise to indemnify, defend and hold harmless the activity sponsor(s) for any injury arising from the described activity. If a dispute over this agreement arises, I (parent/guardian) agrees to resolve the matter through a mutually acceptable alternative dispute resolution process. If I and the activity sponsor cannot agree upon such a process, the dispute will be submitted to a three-member arbitration panel for resolution in accordance with the rules of the American Arbitration Assoc. I agree and sign with my electronic signature below: *
Your answer
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