PLEASE READ CAREFULLY AND SIGN BELOW TO INDICATE YOUR AGREEMENT.
NOTE: THIS FORM INCLUDES A RELEASE OF LIABILITY
Please review and complete the sections below and sign in the space provided to
indicate your agreement with all
statements made in such sections.
AUTHORIZATION AND RELEASE OF LIABILITY
I, the parent or guardian of the above-named child,
authorize the participation of my child in the Upward Unlimited athletic
program (the “Program”) of the above-named Church. My child will participate in
the Upward sport denoted on this brochure.
I understand that this Program is a nonprofit Christian sports ministry program
for youth and that my child’s participation is
voluntary and not essential to completion of requirements of any program, school
or government agency. I understand that
the Program is conducted by the Church and its volunteers and staff, including
parents of other participating children. I also
understand that the Church is solely responsible for all aspects of the Program
including selection and supervision of all
persons conducting the Program, and that Upward Unlimited is not responsible for
the Program or selecting and supervising
persons conducting the Program. I further understand and agree that my child’s
participation in athletic and other activities
of the Program necessarily involves the risk of injury and even death from
various causes, including but not limited to
accidents, falls, strenuous and prolonged physical activity, dehydration,
illness, collision or dispute with other participants,
weather related injuries, playing area and equipment defects, and negligence of
coaches and referees. On behalf of my child,
me, and my family, I assume these risks.
In consideration of the privilege of my child’s participation
in the Program, and on behalf of my child and me as
parent/guardian, I hereby release, discharge, hold harmless and indemnify, and
covenant not to sue, the Church and
Upward Unlimited, and all of the Church’s and Upward Unlimited’s directors,
officers, elders, trustees, deacons, employees,
volunteers, insurers, agents and representatives, and all other persons
associated with the Program (including without
limitation any other participating churches, sponsors, parents, vendors, coaches
and other game and event workers,
officials, drivers, and organizations) as to any and all claims of my child, me
and other family members for personal injuries
suffered by my child, property damage, medical expenses, and economic loss
arising directly or indirectly out of my child’s
participation in the Program, and any first aid, medical care or treatment
provided to my child in the event my child is injured
or becomes ill while participating in Program activities, and excepting claims
that may not be released under applicable law.
This Release of Liability shall be as broadly construed as allowed by law to
include all claims and rights that the child, that
I as parent/guardian, and that other family members may have. I am a legally
responsible parent or guardian of my child.
If any provision of this Release of Liability is deemed invalid, the remaining
provisions shall remain in full force and effect.
This Release of Liability shall be binding on me, my family, heirs, next of kin,
legal representatives, beneficiaries, successors
and assigns. I give permission for free use of my child’s name and picture in
broadcasts, telecasts or written accounts for
any participation in an Upward Unlimited sponsored event.
MEDICAL CONDITIONS
I understand that participation in the Program may
involve strenuous and prolonged physical activity. I agree that my child
is healthy and able to participate in the Program activities.
I understand that the Church or its representatives may
request health information concerning my child and/or ask my child
to undergo a medical exam. If the Church determines that my child does have a
physical or mental condition that may affect
his/her ability to safely and appropriately participate in Program activities,
the Church may determine that my child cannot
be permitted to participate. I understand and agree that, while the Church
desires that all children will be able to participate,
such decisions may have to be made out of concern for the best interests of my
child and other participants.
CONSENT TO MEDICAL TREATMENT
In the event my child is injured or becomes ill in
Program activities, and if I, the parent or guardian of the above-named
child, am not present to make medical decisions, I hereby authorize the Church,
its staff, volunteers including volunteer
parent participants, coaches, assistant coaches, and referees, supervisors and
drivers, to arrange for and consent on my
behalf to emergency medical and dental care and treatment, including tests and
radiological exams, and surgery, and
hospital care and treatment, and to consent to medications for pain and other
conditions as prescribed by medical
personnel attending my child. I am responsible for payment of any medical
charges or expenses not covered by my
insurance or the insurance applicable to my child (if any).
My signature below indicates that all information provided in
this form is true and accurate, and that I fully agree to all
statements made on the form, including but not limited to the Authorization and
Release of Liability, Medical Conditions,
and Consent to Medical Treatment. Each responsible parent/guardian should sign.
Signature: _______________________________________________________________
Printed name:_________________________________________
Date: ______________
Signature: _______________________________________________________________
Printed name:_________________________________________ Date: ______________
If only one parent/guardian signs this form, the following must also be
signed:
I affirm that this form was signed by only one
parent/guardian because (1) I am the sole parent/guardian responsible for the
care and custody of the child due to death or incapacity of the other
parent/guardian or court order, or (2) I have made a good
faith effort to obtain the signature from the other parent/guardian but have not
been able to do so due to causes beyond my
control, and I am not aware of any reason that the other parent/guardian objects
to the child’s participation in the Program.
Signature: _______________________________________________________________
Printed name:_________________________________________ Date: ______________