Adult Release and Waiver of Liability

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Email *

First Name *

Last Name *

Phone *

Address *

Emergency Contact Name *

Emergency Contact Number *

Name of Activity *

I, the undersigned, will be participating in activities at or with the China Regional Church of the Nazarene (hereafter the "activities") on the date(s): *

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 participating in these activities. I understand and agree that neither China Regional 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 as a result of my participation in these activities and hereby release China Regional Church of the Nazarene its trustees, officers, directors, employees, agents and representatives from any injury, harm, damage or death, with 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 China Regional 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. *

I authorize China Regional 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. *

I understand and acknowledge that China Regional 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. *

If you agree to all the statements and conditions in this form, sign this form electronically. Type your name below. *

I consent to China Regional Church of the Nazarene using my likeness for use on its website and/or in promotional materials. *

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