Participation Form
If you have not filled our a Medical Release form within the last year. Please fill it out in conjunction with this form. You can fill out a copy by following this link: http://goo.gl/forms/4Vn7HpiTkDygckMh2
Participant name
Your answer
Date of Birth
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Address
Your answer
Email
Your answer
Phone Number
Your answer
Parent/ Gardian Name
Your answer
Relationship to participant
Your answer
Address
Your answer
Email
Your answer
Phone Number
Your answer
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, the participant (or parent/guardian if participant is a minor) accepts personal financial responsibility for any bodily or personal injury sustained during the activity. Further, the participant (or parent/guardian if participant is a minor) promises to hold harmless the sponsoring organization and its representatives for any injury related to the activity.

Activities can include but are not limited to:
Riding in cars to place around Quincy and the outlying areas, Playing games, sports, interacting with people of the Quincy community, Acting as group to figure out clues, Having a party at a Youth Leaders house, eating candy and other treats or snack, driving to many different destinations around Quincy and the outlying areas to take group pictures.

Responsibility for the participant is accepted when the student has made verbal face to face contact with an adult leader of any event or service. LifePoint will not be responsible if a student decides to leave a service or event unless verbal or written constraints are given to the event or service coordinator by parent or guardian to not allow the student to leave on their own accord.

If a dispute over the agreement or any claim for damages arises, the participant (or parent/guardian if participant is a minor) agrees to resolve the matter through a mutually acceptable arbitration process.

Your typed name will serve as your signature
Your answer
Date
MM
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DD
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YYYY
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