The information required below will be used solely for/during Rolling in Faith programs and is requested in order that the leadership of RIF (Rolling in Faith) be informed of the same before the program begins in case you/your participant requires medical assistance/treatment during the program(s).

In case of emergency, I hereby authorize Rolling in Faith Corporation, its agents, or volunteers, and leaders to contact my physician if listed (or one on call for my physician) and/or my/my participant’s listed contact person. I further hereby authorize Rolling in Faith Corp. to release any and all medical information concerning me/my participant to my physician, if listed, (or one on call for my physician), my contact person, and any and all medical professionals rendering medical treatment/advice to me or another on my behalf during the course of the program.

I agree to any medical treatment that may be required or determined by an agent/volunteer of Rolling in Faith, I further release any person who procures such medical service from any and all liability that may arise from or be attributable to such medical services.


Publicity Release:  I hereby consent that any narratives, depictions, pictures, film, photographs, audio-visual or sound recordings or testimonials of me/my participant made by Rolling in Faith, those acting with its permission, for the purpose of illustration, broadcast, or testimonial shared with the general public in connection with the work of Rolling in Faith Corp.  I assign to Rolling in Faith Corporation all of my rights to these materials.  I understand that these materials made by Rolling in Faith are owned by Rolling in Faith and that they may copyright them. I understand that these materials may disclose my/my participants personal and protected health care information.