Today's Date

MM

DD

YYYY

Participant Name *

First Name

Last Name

Phone *

(###)

###

####

Birthday *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact - In an emergency, please contact the following *

First Name

Last Name

Emergency Contact Phone Number *

(###)

###

####

By checking the box below and submitting this form, I, the undersigned participant, acknowledge and fully understand that I will be engaging in activities that involve risk of serious injury, including permanent disability or death, and severe social and economic losses which might result not only from their own actions, inactions or negligence, but action, inaction or negligence of others, the rules of play, or the condition of the premises or of any equipment used. Further, there may be other unknown risks not reasonably foreseeable at this time, assume all the foregoing risk and accept personal responsibility for the damages following such injury, permanent disability or death, hereby release, discharge, covenants to indemnify and not to sue Living Stones Christian Church, its directors, officers, employees, coaches, managers, agents, sponsors and associated personnel including those of its affiliated organizations, and the owners and lessors of premises used to conduct the event, all of which are hereinafter referred to as 'releasees', from any and all liability to each of the undersigned, his/her heirs or next of kin for any and all against any claim by or on behalf of the applicant as a result of the applicant's participation in the program and/or being transported to or from the same program. I assume all related risks, both known or unknown to me, of my participation in this activity, including travel to, from and during the activity. *

I agree with the disclosure above.

I hereby give my consent to have an athletic trainer, coach, first aid trained persons, and/or doctor of medicine or dentistry or associated personnel to provide the applicant/participant with medical assistance and/or treatment and agree to be financially responsible for the cost of such assistance and/or treatment. I, also agree to save and hold harmless and indemnify each and all parties herein referred to above as releasees from all liability, loss, cost, claim or damage whatsoever, including death or damage to property, which may be imposed upon said releasees because of any defect in or lack of such capacity to so act or caused or alleged to be caused in whole or in part by the negligence of the releasees. I have read the above waiver/release and understand that (I) we have given up substantial rights by signing this release and sign below voluntarily. I understand that this document may not be altered in any manner and that any alteration without the express written consent from Living Stones Christian Church will cause the participant to be removed from the program. *

I agree with the disclosure above.

I have read and fully understand the above waiver and release of all claims. By checking the box below and submitting this form freely, I certify that I am the individual represented above, and that I agree to the terms as stated. *

I agree to the above disclosure