Urban Impact Service Day 5/11/24 Release Form

Sponsoring organization: Waterdam Church Youth Ministry - 208 Galley Rd, Canonsburg, PA 15317 - Church Phone: 724-745-2158

Name of Sponsor Coordinator: Scott MacLeod - Cell Phone: (412)600-6740 - Email: smacleod@waterdam.org

Saturday, May 11, 2024 - Urban Impact, Allegheny Center Alliance Church, Northside - Meet at Waterdam Church 8am; Pickup at Waterdam Church 4pm - Cost $20

Name of Participant(Required)

First Last

Email(Required)

Name of Parents/Guardian(Required)

First Last

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Phone(Required)

Name of Emergency Contact(Required)

First Last

Phone (day)(Required)

Phone (evening)(Required)

List Allergies or Medical Conditions(Required)

Is sponsor authorized to approve medical treatment?(Required)

Yes

Is participant covered by personal/family medical insurance?(Required)

Yes

Name of Insurer

Policy and/or Group Number

Participation Agreement (To be completed by participant or by parents or guardians if participant is a minor)

I acknowledge that participation in the activity described above involves risk to the participant (and to the participant’s parents or guardians, if the participant is a minor), 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 described above (the “activity”), the participant (or parent/guardian if the participant is a minor) acknowledges and accepts the risks of injury associated with participation in and transportation to and from the activity. The participant (or parent/guardian) 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 (or parent/guardian) 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.

Type name for Parent/guardian signature(Required)

First Last

Participant or parent/guardian if participant is a minor

Date(Required)

Comments

This field is for validation purposes and should be left unchanged.

Urban Impact Service Day 5/11/24 Release Form

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Phone: 724.745.2158

Email: churchoffice@waterdam.org

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