Liability Release and Medical Authorization

Home Run Ministries - The Home TEAM

Yoga Class Registration

For ladies and girls ages 15 and up on Mondays from 10:00 am – 11:00 amtaught by Kimberly Thorsen.The $55 per semester (13 sessions) paymentcan be made by cash or check to HRM, PO Box 5926, Kingwood, TX 77325 by August 15, 2018. The first class period will be September 10, 2018, at Kingwood Bible Church, 3610 W. Lake Houston Pkwy, Kingwood, TX 77345. Enter the building through the door to the left of the long covered porch. Class can be joined at anytime throughout the semester by bringing the entire payment amount to the first class attended.

Yoga Liability Release and Medical Authorization for Adults

Participant’s Name:______

Street Address:______City______Zip code______

Contact phone:______Email: ______

Emergency Contact Name:______Emergency Phone: (_____)______

Medical Insurance Carrier:______Policy Number:______

Policy Holder:______

We do hereby release, absolve, and hold harmless the directors, coaches, and adult leaders of Home Run Ministries, Inc. from any and all liability for all losses, damages, or injuries occurring as a result of my presence or participation in any sponsored activities. We also absolve and hold harmless any facility and its directors that Home Run Ministries is using for its activities. We further agree to make or cause to be made, by assignment of third party benefits or otherwise, full and complete payment for examination, treatment, or hospital care required in the case of a medical emergency.

Furthermore, we hereby authorize, in the event of an injury, any director, coach, medical attendant, or adult leader in Home Run Ministries, Inc. to consent to emergency medical treatment for myself when I cannot give consent. Such medical treatment may include, without limitation, x-ray examination, anesthetic, medical, surgical examination or treatment, and general hospital care. Except as noted below, this authorization is given in advance of any specific diagnosis, treatment, or hospital care being required, and is given to provide authority and power on the part of a director, coach, or adult leader of Home Run Ministries to give specific consent to any and all such examination, treatment, or hospital care.

We hereby verify that we understand and accept the terms of this Liability Release and Medical

Authorization.

______

Signature of Adult Participant Date

Please submit form and $55 payment to Karen Griswold, HRM, P. O. Box 5926, Kingwood, TX 77325 (Telephone 281-360-4910) for the Introduction of Yoga class registration. Form and payment can also be hand delivered to HRM at KBC, 3610 W. Lake Houston Pkwy, Kingwood, TX 77345. Non-adult participants must submit HRM, Medical and Liability Release for students.