Please note, the following is ONLY for participants of the Auburn Church of the Nazarene's Back to School Bash on September 7, 2018. Thank you.

I, the parent and/or guardian of the minor participant listed below (the “Minor”), hereby give permission for the Minor to participate in Open Gym at the Champions for Life Sports Center(the “Activity”). I understand the nature of the activity and the Minor’s experience and capabilities and believe the Minor to be qualified, in good health, and in proper physical condition to participate in the Activity. I hereby authorize the Activity staff to seek medical treatment for the Minor as they see necessary at a medical facility. I consent to any x-ray, anesthetic, medical or surgical diagnosis or treatment and hospital care subsequently deemed necessary by a licensed health care provider during the Activity. I understand that this authorization is given in advance of any specific diagnosis, treatment or hospital care, and that it is given to provide the Activity staff authority to seek medical treatment, and to provide a licensed health care provider the authority to administer this treatment as he/she judges necessary to the Minor. I accept responsibility for payment of all services rendered. I authorize any medical facility which renders services to release medical information necessary for the processing of insurance claims.

 

I HEREBY RELEASE, DISCHARGE, COVENANT NOT TO SUE, AND AGREE TO INDEMNIFY AND SAVE AND HOLD HARMLESS CHAMPIONS FOR LIFE, INC., ITS ADMINISTRATORS, DIRECTORS, AGENTS, OFFICERS, MEMBERS, VOLUNTEERS, AND EMPLOYEES, OTHER PARTICIPANTS, ANY SPONSORS, ADVERTISERS, AND OWNERS AND LESSEES OF PREMISES ON WHICH THE ACTIVITY TAKES PLACE (EACH CONSIDERED ONE OF THE "RELEASEES" HEREIN) FROM ALL LIABILITY, CLAIMS, DEMANDS, LOSSES, OR DAMAGES ON THE MINOR’S ACCOUNT CAUSED OR ALLEGED TO BE CAUSED IN WHOLE OR IN PART BY THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE, INCLUDING NEGLIGENT RESCUE OPERATIONS, AND FURTHER AGREE IF, DESPITE THIS RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK, INDEMNITY AND PARENTAL CONSENT AGREEMENT, I, THE MINOR, OR ANYONE ON THE MINOR’S BEHALF MAKES A CLAIM AGAINST ANY OF THE RELEASEES, I WILL INDEMNIFY, SAVE, AND HOLD HARMLESS EACH OF THE RELEASEES FROM ANY LITIGATION EXPENSES, ATTORNEY FEES, LOSS, LIABILITY, DAMAGE, OR COST WHICH THE RELEASEES MAY INCUR AS THE RESULT OF ANY SUCH CLAIM.

 

Please read the above, and fill out the form below. By doing so, you indicate that you understand and agree with the waiver and release as written above. 
All participants over age 18 (or their parent if under 18) on the roster for the event must fill out this page. 

Parent Name *
Parent Name
Participant Name *
Participant Name
Participant Date of Birth *
Participant Date of Birth