Cornerstone Skatepark Waiver 2023
17575 Euclid Street Fountain Valley California 92708 | 714-962-5412

IN ORDER TO SKATEBOARD OR ROLLERBLADE YOU MUST DO THE FOLLOWING:

• Completely fill out this form by your parent or legal guardian. We cannot accept this form from friends, host-families, grandparents, aunts, uncles, step-parents, or other relatives.

• Meet grade/age policies. Parents/guardians, family and friends of skaters or blader are welcome to come and observe all our programs, but may not skate or rollerblade unless they are registered and meet the age requirements of that particular program. Those over 18 must sign their own form.

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Email *
Participants Full Name *
Phone Number *
Participant's Birthdate *
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Home Address *
CORNERSTONE CHRISTIAN FELLOWSHIP ACKNOWLEDGEMENT / AGREEMENT / WAIVER/ASSUMPTION OF RISK TOINDEMNIFY FOR MINORS AND ADULT PARTICIPANTS: I, The undersigned, (hereinafter referred to as the “Undersigned”) do agree to indemnify Cornerstone Christian Fellowship (hereinafter “CCF”) upon the reception of this CCF extreme sports ministry / acknowledgement / agreement / waiver / assumption of risk to indemnify (hereinafter referred to as the “Agreement”) and hereby grant permission to the above named person to participate (hereinafter “Participant”) in the extreme sports ministry of CCF subject to the following conditions, requirement and Agreement: 1. The Undersigned (parent/legal guardian of Participant or adult Participant) understands, acknowledges, and agrees that this Agreement applies whether the Participant in CCF is an observer, a bystander, or an active participant, whether the activity is at the above stated premises, adjacent CCF properties or on an outing, including traveling to or from such activities. 2. I understand that the Participant must obey and respect all the CCF rules and volunteers, CCF pastors, staff, interns, (hereinafter “Staff”) at all CCF events. 3. The Undersigned acknowledges, understands, and agrees that skateboarding, BMX, in-line skating, and other extreme sports and dangerous and can result in injury, death, or personal property damage, and is fully aware of the risks and hazards inherent to such activities and hereby enrolls voluntarily the Participant, knowing the present condition of CCF’s ramps, equipment, facilities, and property with full knowledge that the said condition may become more hazardous and dangerous at any time while the Participant is involved in/with CCF. 4. The Undersigned hereby voluntarily assumes all risk of loss, theft, damage, injury, or death that may be sustained by the Participant and any damage to or theft/loss of his/her property while in CCF and understands that various degrees of experience and skill are required for the different ramps and riding surfaces and agrees that it will be the Participant’s sole judgment as to what the Participant will attempt to ride/do. 5. In consideration and upon the reception of this CCF Agreement, the Undersigned hereby releases CCF on behalf of the abovenamed Participant, his/her heirs, assigns, and legal representatives from any and all liability for personal injuries or property damage/theft/loss or death arising out of the Participant’s involvement, whether or not the said injuries, death, damages/losses/thefts were caused by the negligent care of facilities, ramps, equipment, observation areas or by the CCF Staff. The Participant and Undersigned agree never to sue any CCF Staff or entities in connection with any and all damages, losses, claims, demands, rights, actions, and causes of action of whatever nature whether injuries, death, or damages/losses/thefts to the property of the Participant. 6. The Undersigned agrees for himself/herself, and for his/her heirs and legal representatives to indemnify CCF, its Staff, volunteers and attendees, against and to save and hold harmless from any and all damages, actions, causes of action, claims, judgements, costs of litigation and attorney’s fees, which may in any way and at any time result from the Participant’s involvement in/with CCF 7. CCF may immediately revoke this Agreement for any violations of any of its terms. 8. Under the penalty of perjury, the Undersigned does warrant to CCF that all the information given on this registration form is true, current and accurate. 9. I as the parent/legal guardian of the Participant have read, and understand and consent to the terms above and to the minor becoming a Participant.                                                                                           Please enter your name here as the parent/legal guardian signature: *
Does the participant have any allergies to food, medicine or a medical/physical condition which our staff or medical/dental professionals should be aware of? *
Explain any allergies to food, medicine or a medical/physical condition here:
Does the participant have medical insurance? *
List insurance company and policy number here:
Provide local hospital that your insurance accepts (Fountain Valley Regional, OC Memorial, Hoag, CHOC?) *
Emergency Contact Name other than parent/legal guardian *
Emergency Contact Number other than parent/legal guardian *
Emergency Contact relation to participant (grandparent, aunt, uncle, cousin, older sibling?) *
By entering your name here, under the penalty of perjury, the undersigned does warrant Cornerstone that all information given on this form is true, current and accurate. As the parent/legal guardian of the minor participant, you have read, understand and consent to the terms below:                        CORNERSTONE CHRISTIAN FELLOWSHIP EMERGENCY MEDICAL/DENTAL RELEASE AND CONSENT AGREEMENT 1. The Undersigned does hereby authorities Cornerstone Christian Fellowship Staff to consent to IMMEDIATE FIRST AID AND MEDICAL CARE, any X-ray examination, anesthetic, medical, dental, or surgical diagnosis or treatment and hospital care for the Participant (named on the reverse side of this form) which is deemed advisable by and to be rendered under the general or special supervision of any physician or surgeon, licensed under the provision of the Medicine Practice Act or any dentist licensed under the Dental Practice Act, at any hospital, dental, or elsewhere. 2. I understand that my insurance and/or my finances will cover any such treatment and CCF will not be liable whether or not insured. 3. I understand that the Participant will be taken to the below stated hospital (if specified) by car by CCF or Ambulance if a CCF Staff person believes that that the Participant may need medical/dental attention only when the incident occurs within the city limits of the Fountain Valley area. I understand that incidents, accidents, physical/medical, and dental emergencies which occur on retreats, camps, outings, trips, and activities outside the Fountain Valley city limits will be treated at a nearby hospital or medical/dental facility whether or not my insurance applies at such a facility and I assume total financial responsibility for payment of all such services. 4. It is understood that an effort shall be made to contact the Undersigned prior to rendering treatment to the Participant, but that any of the above treatment will not be withheld if the Undersigned is not reached. 5. I, the Undersigned do hereby authorize CCF to act as my agent in presenting this Agreement to any qualified medical/dental practitioners and I will not hold CCF liable for treatments rendered 6. I also give permission for the authorized CCF Staff to administer medication the Participant has to take. I will provide the authorized CCF Staff with this medication in the original container with specified written instruction on the container for its dispensing. 7. This authorization will remain effective whether the Participant is in route to or from, participating, observing, or standing by any program or activity of CCF unless previously revoked by the Undersigned in writing and delivered by registered mail to CCF 8. I understand that it is my responsibility to inform, in writing, the CCF Staff in the case that the Participant’s information, insurance carrier, specified local hospital, or medical/physical condition changes.                                                                   Please enter your name here as the parent/legal guardian signature: *
A copy of your responses will be emailed to the address you provided.
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