Adult Release and Waiver of Liability (New Future)
Please fill out this form and click submit before attending the desired function.
Name
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Email
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This address will receive a confirmation email
Phone
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Emergency Contact Name
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Emergency Contact Number
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Name of Activity
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I, the undersigned, will be participating in activities at the Lombard Church of the Nazarene (hereafter the “activities”) on the date(s):
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I recognize that there are risks involved in participating in these activities and hereby assume all risk of injury, harm, damage, or death in connection with my participation in these activities. I understand and agree that neither Lombard Church of the Nazarene, nor its trustees, officers, directors, employees, agents or representatives may be held liable in any way for any injury, harm, damage, or death that may occur to me as a result of my participation in these activities and hereby release Lombard Church of the Nazarene its trustees, officers, directors, employees, agents and representatives from any injury, harm, damage or death, which may occur while I am participating in the activities throughout the year. To the fullest extent permitted by law, I agree to save and hold harmless Lombard Church of the Nazarene its trustees, officers, directors, employees, agents and representatives from any claim by myself, my estate, heirs, successors, assigns or other persons arising out of my participation in the activity. Initial below.
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I authorize Lombard Church of the Nazarene through its trustees, officers, directors, employees, agents or representatives to render or obtain such emergency medical care or treatment for me as may be necessary should any injury, harm or accident occur to me while participating in this activity. Initial below.
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I understand and acknowledge that Lombard Church of the Nazarene does not provide health or medical insurance in connection with the activity and I agree that I will be financially responsible for any bills incurred as a result of medical treatment, including emergency medical treatment and/or transportation to a medical facility, in connection with my participation in the activity. Initial below.
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If you agree to all of the statements and conditions in this form, sign this form electronically. Type your name below.
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I consent to Lombard Church of the Nazarene using my likeness for use on its website and/or in promotional materials.
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Please select all that apply.
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Description
Please fill out this form and click submit before attending the desired function.
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