midlandevangelicalfreechurch
General Release Hold Harmless Agreement

Registration Information

Name of Activity: / Impact Trip 2017
Name of Participant: / Click here to enter text. /
Email: / Click here to enter text. / Telephone: / Click here to enter text. /
Address: / Click here to enter text. / City: / Click here to enter text. / State: / Click here to enter text. / Zip: / Click here to enter text. /
Name(s) of parent/guardian if participant is a minor: / Click here to enter text. / Telephone: / Click here to enter text. /
Name of emergency contact: / Click here to enter text. / Telephone: / Click here to enter text. /
Does participant have any Life Threatening allergies &/or medical conditions? / Yes*☐ No ☐
Allergy/condition: / Click here to enter text. / Reaction: / Click here to enter text. /
*(office use: Make sure participant has completed Life Threatening Allergy & Medical Condition Form)
Is Midland Free and/or activity coordinator authorized to approve medical treatment? / Yes ☐ No ☐
Is participant covered by personal/family medical insurance? / Yes ☐ No ☐
If yes, name of insurance provider: / Click here to enter text. /
Policy or group number: / Click here to enter text. /
Photo/Video Consent
Pictures or video may be taken of participant(s) for Midland Free:
Internal Use (posters & flyers) / Yes ☐ No ☐ / External Use (church website /or Facebook) Yes ☐ No ☐

Physical Injury Hold Harmless Agreement

The participant (or parent/guardian if participant is a minor) acknowledges and accepts the risks of physical injury associated with participation in the activity listed above. Except for gross negligence on the part of Midland Free, the participant (or parent/guardian if participant is a minor) accepts personal financial responsibility for any injury sustained during the activity.

Safety of Children Hold Harmless Agreement

Midland Free’s Safety of Children Policy as stated in Section II of the Facility Use Agreement (available upon request) requires two background checked and approved adults to be present in the company of children under 18 years old, and all participants stay in open and clearly visible areas during the activity. The participant (or parent/guardian if participant is a minor) acknowledges and accepts that this policy may not always be adhered to during this activity.
By signing below, the participant (or parent/guardian if participant is a minor) accepts full responsibility for any injury sustained and for the care and safety of the participant during the activity listed and as outlined in the Hold Harmless Agreements above. The participant (or parent/guardian if participant is a minor) agrees to indemnify and hold harmless Midland Free, its staff, members and Board of Elders against any liability or legal action that might result from any injury or loss suffered by the participants if loss or injury is a consequence of participation in the activity. This includes any expenses, damages, liabilities, losses, actual attorney’s fees and and/or judgments arising out of or in connection with, any claim, demand or action made by any party as a result of the activity or event. If a dispute over this agreement or any claim for damages arises, the participant (or parent/guardian) agrees to resolve the matter through arbitration.
Signature: / Click here to enter text. / Date: / Click here to enter text. /
(Participant or parent/guardian if participant is a minor)

2017 Impact General Release Hold Harmless Agreement.doc12/1/16