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Medical Release Form
Waiver Form
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Parents Name
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First
Last
I HEREBY WAIVE & RELEASE Northridge Church and agents, employees, officers, directors, affiliates, successors and assigns, from liability pertaining to the matters set forth below. I understand that by signing this Waiver & Release, I expressly and willing agree to assume complete responsibility for any risk of injury that may arise from the below related activity. On behalf of myself, my heirs, assigns and next of kin, I waive all claims for damages, injuries and death sustained to me or my property that I may have against the above named Released Party relating to such activity. I understand that the activities that my child will participate in are inherently dangerous and may cause serious injuries, including bodily injury, damage to personal property and/or death. By this waiver, I assume any risk, and take full responsibility and waive any and all claims of personal injury, including severe bodily injury, damage to personal property and death relating to all activities associated with Northridge Church. If I am injured from said activity, I will not hold Released Party responsible even if the injuries were caused by negligence on my part or the Released Party, or any other party under or affiliated with the above named Released Party.
My Child listed below has no limitations, medical ailments, physical or mental disabilities that would limit or prevent him/her from participating in the above mentioned activity, and, if required, will obtain a medical examination and clearance.
I HAVE READ AND FULLY AGREE TO THE TERMS OF THIS WAIVER AND RELEASE. I UNDERSTAND AND CONFIRM THAT BY SIGNING THIS WAIVER AND RELEASE I HAVE GIVEN UP CONSIDERABLE FUTURE LEGAL RIGHTS. I HAVE SIGNED THIS WAIVER FREELY, VOLUNTARILY, UNDER NO DURESS OR THREAT OF DURESS, WITHOUT INDUCEMENT, PROMISE OR GUARANTEE BEING COMMUNICATED TO ME. MY SIGNATURE IS PROOF OF MY INTENTION TO EXECUTE A COMPLETE AND UNCONDITIONAL WAIVER AND RELEASE OF ALL LIABILITY TO THE FULL EXTENT OF THE LAW. I AM 12 YEARS OF AGE OR OLDER AND MENTALLY COMPETENT TO ENTER GRANT THIS WAIVER.
Select one
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I accept the above statement to be true.
I decline the above statement.
Accept or Decline
Child's Name
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First
Last
If you have more than 2 children, please fill out a separate form for the additional children.
2nd Person Registering
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First
Last
If there is more than 3 children registering, please fill out a second registration form with same information. Thank you.
3rd Person Registering
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First
Last
If there is more than 3 children registering under one adult/parent, please fill out a second registration form.
List any known allergies or medical conditions.
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Please list child's name next to allergy or medical condition, if more than one child applies. If there are none, please say "n/a"
Parent Phone Number
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Email Address
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Emergency same as parent
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yes
no
Emergency Name
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First
Last
Emergency Phone Number
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Emergency Contact Relationship to child
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