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BOuLDer Youth Fellowship Participation Waiver

Participant Name *
Participant Name
Parent/Legal Guardian Name *
Parent/Legal Guardian Name
Emergency Contact Phone *
Emergency Contact Phone
Physician's Name *
Physician's Name
Physician's Phone Number
Physician's Phone Number
Policy Holder's Name *
Policy Holder's Name
I/We understand all reasonable safety precautions will be taken at all times by Living Stones Christian Church and its agents during the events and activities. I/We authorize any treatment by an accredited hospital and/or physician deemed necessary for the subject of the release in case of an emergency. I/We underestand the possibility of unforeseen hazards and know the inherent possibility of risk. I/We agree not to hold Living Stones Christian Church, its leaders, employees, or volunteer staff liable for damages, losses, diseases, or injuries incurred by the subject of this form. *
I/We authorize any treatment by an accredited first aid respondent, hospital and/or physician deemed necessary for the subject of the release in case of an emergency. *
I have read and fully understand the above waiver and release of all claims. By checking the box and submitting this form, I certify that I am the individual represented (or guardian of the individual) above, and that I agree to the terms as stated. *