Medical and Liability Waiver
Northgate Baptist Church
Medical Authorization Agreement and Waiver of Liability, Release and Indemnification
(Effective for One Year from Date of Signing)
Please read this Agreement carefully. Your signature below indicates that you have read and understand every provision of this Agreement, and that you unequivocally agree to all terms, conditions, and promises herein. By signing below, I, as an Adult Participant or on behalf of the Minor Participant (hereinafter jointly and separately referred to as the "Participant") agree as follows:
I understand and acknowledge that Northgate Baptist Church (hereinafter "Northgate") does not offer or provide medical care of any nature or type at its facilities or with any of its programs and activities, whether those are onsite or offsite. SWO has no physician or nurse on its staff. Northgate does have and can provide a limited selection of "over the counter" medications to Participants (e.g. Tylenol, Ibuprofen, etc.), but I understand and agree that the decision as to whether such medications will be taken by the Participant is the sole and exclusive responsibility of the Participant and/or the adult leader accompanying the Participant.
AUTHORIZATION AND CONSENT FOR MEDICAL CARE: I hereby authorize and consent to any physician(s), nurse, and/or staff of any medical care provider to examine, diagnose, treat, test, and care for the Participant as necessary while the Participant is attending and/or participating in any events or activities with Northgate. Said medical care may be given without any further permission or authorization from me. This consent should be interpreted to authorize the provision of any and all medical care to the Participant deemed reasonably necessary by any medical provider.
RESPONSIBILITY FOR MEDICAL EXPENSES: I also authorize payment of medical benefits for any medical care furnished to the Participant by any medical care provider. I authorize you to release to my insurance company information concerning the health care provided to the Participant while participating with Northgate. In the event of any injury or illness requiring transportation to an independent medical facility, I authorize the release of all medical records generated at the facility to the medical staff at Northgate. I understand this will enable a continuity of care upon the participant's return to Northgate and will provide staff and volunteers a means of informing family members of the participant's medical condition. I assume and accept full, complete and sole financial responsibility for any and all costs and expenses that may arise from any and all medical care received by the Participant during the Participant's participation with SWO. "Medical care" is given its broadest interpretation and includes, but is not limited to, ambulance transportation, rescue, evacuation, examination, testing, x-rays and other diagnostic imaging, diagnoses and treatment.
RELEASE OF ALL CLAIMS, COVENANT NOT TO SUE, AND INDEMNITY AGREEMENT: I, individually and on behalf of the Participant, hereby release, discharge, waive and promise not to sue NORTHGATE BAPTIST CHURCH and/or their respective owners, shareholders, officers, directors, members, managers, administrators, agents, employees and/or volunteers, and/or other participants, officials, rescue personnel, sponsors, advertisers, owners and lessees of the premises where Northgate is conducted or where off-campus activities are conducted (collectively "RELEASEES"), FROM/FOR ANY AND ALL LIABILITY, CLAIMS, DEMANDS, LOSSES, OR DAMAGES CAUSED OR ALLEGED ARISING FROM OR RELATED TO ANY AND ALL MEDICAL CARE RECEIVED BY THE PARTICIPANT WHILE PARTICIPATING IN ACTIVITIES AT OR ATTENDING NORTHGATE, INCLUDING ANY AND ALL CLAIMS ALLEGED FOR EMOTIONAL DISTRESS and/or CLAIMS ARISING FROM NEGLIGENT RESCUE AND/OR EMERGENCY RESPONSE OPERATIONS.
I FURTHER AGREE THAT IF, DESPITE THIS RELEASE, I, THE PARTICIPANT, OR ANYONE ON THE PARTICIPANT'S BEHALF MAKES A CLAIM ARISING FROM ANY INJURY (INCLUDING DEATH), LOSS, AND/OR DAMAGE EXPERIENCED BY ME OR THE PARTICIPANT ARISING FROM MEDICAL CARE PROVIDED TO THE PARTICIPANT, I AGREE TO INDEMNIFY, DEFEND AND HOLD HARMLESS EACH AND ALL OF THE RELEASEES FROM ANY AND ALL LITIGATION EXPENSES, ATTORNEYS FEES, LOSS LIABILITY, DAMAGES, AND/OR ANY OTHER COSTS THAT MAY OCCUR AS A RESULT OF ANY SUCH CLAIM.
FORUM SELECTION AND CHOICE OF LAW: I agree that in the event that any claim or dispute of any nature arises out or relating to 1) the Participant's participation with Northgate on or off its premises, 2) this Agreement and/or 3) the Participant's participation with any activity offered through or by Northgate, such claim or suit shall only be brought in the South Carolina state courts located in Greenville County and that only South Carolina law shall apply to any such claim or suit.
By signing this on behalf of a Minor Participant, I understand that I am binding myself and the Minor Participant as set out above and that this Agreement is fully integrated and supercedes any oral or written expressions between the Parties about Northgate and participation with its activities.
Below is an electronic signature of my name that, for purposes of this Agreement, I adopt as my signature. I agree that this electronic signature is the legally binding equivalent of my handwritten signature on paper. I waive any and all claims that the electronic signature below does not legally bind me to the terms of this Agreement. By signing, I understand that I am signing this Agreement with the intent of being bound by all of its terms. I further acknowledge that I have read and fully understand the terms of the Agreement; I voluntarily agree to be bound by this Agreement; and I certify that I am 18 years of age or older.
