Meeting Place Church Minor Participation Agreement

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Email *

First and Last Name of Student *

Student's Gender at Birth *

Male

Female

Student's Birthday *

YYYY

Name of Parent/Legal Guardian *

Address *

City *

Zip Code *

Phone Number *

Emergency Contact and Number

List of Allergies and Medical Conditions *

Is Sponsor authorized to approve medical treatment *

Yes

Is Student Covered by Insurance *

Yes

Name of Insurer *

Policy or Group number *

What Event is Student Participating In *

I understand that participation in activities sponsored by Meeting Place Church Assembly of God (MPC), located at 920 HWY 96 N, Fairview, TN 37062 may result in various types of injury including, but not limited to, the following: sickness, bodily injury, death, emotional injury, personal injury, property damage, and financial damage. In consideration for the opportunity to participate in activities with Meeting Place Church Assembly of God, the parent/legal guardian of the minor acknowledges and accepts the risks of injury associated with participation in and transportation to and from activities. The parent/guardian accepts personal financial responsibility for any injury or other loss sustained during activities or transportation to and from activities, as well as for any medical treatment rendered to the minor that is authorized by a MPC sponsor or its agents, employees, volunteers, or other representatives (Collectiveley referred to as the "activity sponsor" hereinafter) Further, the parent/guardian releases and promises to indemnify, defend and hold harmless the "active sponsor" for any injury arising directly or indirectly out of the activities or transportation to and from activities, wether such injury arises out of negligence of the active sponsor, the minor, or otherwise. If a dispute over this agreement or any claim for damages arises, the parent/guardian agrees to resolve the matter through a mutually acceptable dispute resolution process *

Yes

Legal Digital Signature *

Date *

YYYY

A copy of your responses will be emailed to the address you provided.

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