The Anchor Youth Event

Waiver Form

Colonial Heights Assembly of God 5200 S. Broadway Wichita KS 67216 316-524-3068

Participant Information (To be completed by a parent or an authorized guardian if the participant is a minor.)

Name of Participant

First Name

Last Name

Email

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact Information

First Name

Last Name

Email

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Is the youth sponsor authorized to approve medical treatment?

Yes

No

Is the participant covered by personal/family medical insurance?

Yes

No

If yes, please provide your Insurance Provider and Policy Group Number:

Participant Agreement

By signing below, the participant (or parent/guardian if the participant is a minor) acknowledges and accepts the risks of physical injury associated with participating in the group activity, except for gross negligence on the part of the sponsor and/or its representatives, including employees and/or volunteers, the participant (or parent/guardian) accepts personal financial responsibility for any bodily or personal injury sustained during the activity. Further, the participant (or parent/guardian) promises to hold harmless the sponsor and its representatives, including employees, and volunteers, for any injury related to the activity. 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 arbitration process. Print Name for a signature (Participant or parent/guardian if participant is a minor):

Date

MM

DD

YYYY

Participating Event

The Anchor Youth Event

Waiver Form

Site Title