Liability and Medical Release Youth Name of Sponsoring Organization * Name of Sponsor's Coordinator * Description of Activity * Name of Participant First Name Last Name Name of Parents/guardians * First Name Last Name Address Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Phone * (###) ### #### Emergency Contact Name First Name Last Name Emergency Contact Phone (###) ### #### Allergies Is sponsor authorized to approve medical treatment? Yes No Is participant covered by personal.family medical insurance? Yes No Name of Insurer Policy or group number Participation Agreement. I acknowledge that participation in the activity described above involves risk to the participant (and to the participant’s parents or guardians, if the participant is a minor), and 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 the activity described above (the “activity”), the participant (or parent/guardian if the participant is a minor) acknowledges and accepts the risks of injury associated with participation in and transportation to and from the activity. The participant (or parent/guardian) accepts personal financial responsibility for any injury or other loss sustained during the activity or during transportation to and from the activity, as well as for any medical treatment rendered to the participant that is authorized by the sponsor or its agents, employees, volunteers, or any other representatives (collectively referred to as the “activity sponsor”). Further, the participant (or parent/guardian) releases and promises to indemnify, defend, and hold harmless the activity sponsor for any injury arising directly or indirectly out of the described activity or transportation to and from the activity, whether such injury arises out of the negligence of the activity sponsor, the participant, or otherwise. If a dispute over this agreement or any claim for damages arises, the participant (or parent/guardian) agrees to resolve the matter through a mutually acceptable alternative dispute resolution process. If the participant (or parent/guardian) and the activity sponsor cannot agree upon such a process, the dispute will be submitted to a three-member arbitration panel for resolution in accordance with the rules of the American Arbitration Association. Print Name below Parents confirmation signature First Name Last Name The name above is my electronic signature I agree Thank you!
