Release Form

Participant Name *

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

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Emergency contact

First Name

Last Name

Phone *

(###)

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Name Insured *

First Name

Last Name

PARTICIPATION AGREEMENT/INJURY WAIVE *

As a parent/guardian of above mentioned minor do hereby release, acquit, hold harmless, and forever discharge Council Road Baptist Church (CRBC), its agents, agencies, servants, employees, and all persons, natural or corporate, in privatives with them, from any and all claims or causes of action of any kind whatsoever, including, but not limited to actions, suits and/or claims, from any bodily injuries, death, or property damage which may be sustained by my minor child/ward, while participating in the stated activity, including travel to and from such activities, not resulting from the intentional act or acts by any agent, servant, or employee of CRBC. It is acknowledged that my decision to allow my minor child/ward to engage in the stated activity I entered into freely, and that CRBC, its agents, agencies, servants, and employees have not influenced my decision to allow my child/ward to engage in such activities. I acknowledge that CRBC is unwilling to permit my minor child/ward to participate in the stated activity without a signed waiver by me.This waiver shall include the stated activity and ends when the listed child/ward is retrieved from CRBC’s care. Unless/until this waiver is revoked in writing by me as the parent/guardian with the revocation delivered to the appropriate party at CRBC, this waiver is binding and shall be in full force and effect as long as my minor child/ward is participating in the stated activity. If revoked, such revocation does not revoke prior use or any injuries already incurred/sustained. I hereby agree to indemnify and hold CRBC harmless from any type of injury or loss that my minor child/ward sustains or incurs, if ever. My agreement to indemnify and hold CRBC harmless is continuing in nature and shall not be considered ineffective unless and until waiver is revoked. (I agree that I am authorized to sign on behalf of the person stated above)

I agree to the statement above