Liability Release Waiver


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Carmel Baptist Church Release & Consent Agreement for Youth I hereby, for myself, my heirs, executors, and administrators, waive and forever discharge any and all right and claims for damages which I may have or which may hereafter accrue to me against CARMEL BAPTIST CHURCH, their members, respective officers, agents, representatives, successors, and/or assigns, individually or collectively for any and all damages and liabilities which may be sustained and suffered by me in connection with my association with/or arising out of my traveling with, participation in, and returning from any activity sponsored by CARMEL BAPTIST CHURCH. The youth and others whose signature are attached below do hereby consent to any and all medical and surgical treatments including anesthesia and operations which may be deemed advisable by his or her physician and surgeons. I (we) understand that in the event medical treatment is required, every effort will be made to contact me. However, if I cannot be reached, I give my permission to the staff or sponsor to secure the services of a licensed physician to provide necessary care, including anesthesia, for my child’s wellbeing. I give my consent and permission for the taking of photograph and/or video of my child during the described event and waive and/or assign any and all rights (including copyright) for use in various media including website. In witness of our consent and agreement to the matters stated in the preceding sentences, we have subscribed our signatures below.

DATE: ________________

*Participants SS #______________________________

PARTICIPANT’S NAME: ____________________________________________________________________ (Please print) LAST FIRST MIDDLE ADDRESS: _________________________________________________________________________________ STREET CITY/STATE/ZIP HOME PHONE:_____________________ PARENT’S WORK PHONE: _____________________________ Do you take any medication on a regular basis? ______ Yes ______ No If yes, please describe _______________________________________________________________________ (If you are on medication during this trip, please notify the adults in charge) In the event parents cannot be reached, please call: ______________________________________________ Relationship: ___________________________ Phone: ____________________________________ PARTICIPANT’S SIGNATURE: ______________________________________________________________ INSURED PERSON’S NAME: ________________________________________________________ INSURANCE COMPANY: ___________________________________________________________ POLICY NUMBER: _________________________________________________________________ _______________________________________ Signature of Parent or Guardian

* Your child’s social security number is OPTIONAL. If your child has to go to the hospital, the hospital will bill your insurance company if you have their social security number; if you don’t have the social security number the hospital will bill you and you will submit the bill to your insurance company.

QUEEN CITY JUMP, LLC ASSUMPTION OF RISK, WAIVER AND INDEMNITY AGREEMENT PLEASE READ THIS AGREEMENT CAREFULLY IN CONSIDERATION of the people listed below being permitted to enter into the facilities offered by Queen City Jump, LLC and/or participate in any activities at Queen City Jump, I, the undersigned, agree as follows: 1. The activities offered by Queen City Jump require strenuous exercise and various degrees of skill. I understand the risks and danger of personal injury, disability and/or death to me and/or the child(ren) listed below as a result of participating in the activities offered by Queen City Jump. I assume all risk of damage or injury to myself and the child(ren) listed below. 2. I understand that both I and the child(ren) listed below may be unfamiliar with the surroundings and activities at Queen City Jump facilities and there may be risks, including property damage,  bodily  injury  or  death  (“Risks”).    I  understand   that Queen City Jump, and its members, managers, directors, officers, agents, employees, volunteers, and individuals acting on its behalf  (collectively,   “Queen City Jump”)  cannot  and  do  not  assume  responsibility   for  such  Risks  EVEN  IF   ANY  SUCH   RISKS ARE A RESULT OF THE NEGLIGENCE OR GROSS NEGLIGENCE OF QUEEN CITY JUMP. I FULLY AND VOLUNTARILY ACCEPT AND ASSUME ALL SUCH RISKS ON MY BEHALF AND ON BEHALF OF THE CHILD(REN) LISTED BELOW. 3. IN CONSIDERATION OF BEING PERMITTED TO PARTICIPATE IN THE EVENT, ON BEHALF OF MYSELF, THE CHILD(REN) LISTED BELOW, MY FAMILY, HEIRS, ASSIGNS, AND PERSONAL REPRESENTATIVE(S), I AGREE TO ASSUME ALL THE RISKS AND RESPONSIBILITIES SURROUNDING THE ACTIVITIES OFFERED BY QUEEN CITY JUMP. IN ADVANCE, I RELEASE, WAIVE, FOREVER DISCHARGE, AND COVENANT NOT TO SUE QUEEN CITY JUMP FROM AND AGAINST ANY AND ALL LIABILITY FOR ANY HARM, DAMAGE, CLAIM, DEMAND, ACTION, CAUSE OF ACTION, COST OR EXPENSE OF ANY NATURE THAT I MAY HAVE, NOW OR IN THE FUTURE, ARISING OUT OF OR RELATED TO ANY LOSS, DAMAGE OR INJURY, INCLUDING BUT NOT LIMITED TO MEDICAL EXPENSES, SUFFERING OR DEATH, THAT MAY BE SUSTAINED BY ME, THE CHILD(REN) LISTED BELOW OR ANY PROPERTY, WHETHER CAUSED BY THE NEGLIGENCE OR GROSS NEGLIGENCE OF QUEEN CITY JUMP AND ITS AFFILIATES WITH REGARD TO ANY ACTIVITIES OR FACILITIES AT THE EVENT. IT IS MY EXPRESS INTENT THAT THIS RELEASE SHALL BE DEEMED A RELEASE, WAIVER, DISCHARGE AND COVENANT NOT TO SUE QUEEN CITY JUMP. 4. I AGREE TO SAVE AND HOLD HARMLESS, INDEMNIFY, AND DEFEND QUEEN CITY JUMP FROM ANY CLAIM BY ME, MY FAMILY, THE CHILD(REN) LISTED BELOW OR ANY OTHER PARTY ARISING OUT OF OR IN ANY WAY CONNECTED TO INJURIES TO ME AND/OR THE CHILD(REN) LISTED BELOW ARISING OUT OF THE AVTIVITIES AT QUEEN CITY JUMP FACILITIES, INCLUDING, BUT NOT LIMITED TO, REASONABLE ATTORNEYS’  FEES  INCURRED BY QUEEN CITY JUMP IN CONNECTION THEREWITH. 5. I agree that any controversy or claim arising out of or in any way connected to injuries to me and/or the child(ren) listed below relating to the activities at Queen City Jump facilities shall be settled by binding arbitration administered pursuant to the American Arbitration Association Arbitration Rules, and judgment on the award rendered by the arbitrator(s) may be entered in any court having jurisdiction thereof. I understand and agree that this arbitration provision applies to any claims by me, my family, and/or the child(ren) listed below. 6. I understand and agree that both I and the child(ren) listed below may be photographed, videotaped, recorded on digital media, and/or interviewed for the purpose of Queen City Jump promotional use. 7. I agree that my participation and/or the participation by the child(ren) listed below in activities at Queen City Jump facilities is   completely   voluntary.     I   certify   that   I’m   over   18   years   of   age   and   have   had   an   opportunity   to   ask   any   and   all   questions regarding the terms of this Agreement. I HAVE READ THIS DOCUMENT CAREFULLY, AND I ACKNOWLEDGE AND UNDERSTAND THE EFFECTS OF MY ASSUMPTIONS, RESPONSIBILITIES, RELEASES, WAIVERS, AND INDEMNIFICATIONS. _____________________________ Signed

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CHILDREN NAME

AGE

DATE OF BIRTH

Print Name

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_____________________________________________ Address

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___________________ City _________________ Phone 546557.3

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__________________________ Email