Medical Release (Adults)

Adult Participant's Information

First Name

Last Name

Phone Number

Date of birth

Address

Apartment, suite, etc.

City

State

Postal / Zip Code

Medical conditions, food or medication allergies or any other allergies:

List medications taken regularly:

Is Zach Mulvihill authorized to approve medical treatment in the event that your emergency contact can not be reached?

Yes

Is participant covered by personal/family medical insurance?

Yes

Insurance Info

Insurance Company

Policy Number

Group Number

Emergency Contact Information

First Name

Last Name

Phone Number

Relationship

Participation Agreement
I, the undersigned, acknowledge that participation in the Senior High Ski Trip sponsored by Hillcrest Evangelical Free Church, March 9-12, 2023, involves risk to the participant, and may result in various types of injury including, but not limited to, the following: sickness, bodily injury, death, emotional injury, personal injury, property damage, and financial damage. In consideration for the opportunity to participate in the activity, the participant acknowledges and accepts the risks of injury associated with participation in and transportation to and from the activity. The participant accepts personal financial responsibility for any injury or other loss sustained during the activity or during transportation to and from the activity, as well as for any medical treatment rendered to the participant that is authorized by the sponsor or its agents, employees, volunteers, or any other representatives (collectively referred to as the “activity sponsor”). Further, the participant releases and promises to indemnify, defend, and hold harmless the activity sponsor for any injury arising directly or indirectly out of the described activity or transportation to and from the activity, whether such injury arises out of the negligence of the activity sponsor, the participant, or otherwise. If a dispute over this agreement or any claim for damages arises, the participant (or parent/guardian) agrees to resolve the matter through a mutually acceptable alternative dispute resolution process. If the participant (or parent/guardian) 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 Association.

PHOTO RELEASE
I, the undersigned, grant Hillcrest Evangelical Free Church permission to use photographs and video containing my image in its future publications (weekly emails, bulletin inserts, slideshows, promotional material, the Hillcrest Evangelical Free Church Facebook page, and hillcrestefc.org.

Signature

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