COLEX Release of Liability Form

1
Trip Name (the "Event/Trip")* This field is required.
2024 Bellarmine Spring Break
2024 Centre Spring Break
2024 EKU Spring Break
2024 NKU Spring Break
2024 UK Men's Spring Break
2024 UK Women's Spring Break
2024 WKU Spring Break
2
Your Name (the "Participant")* This field is required.
First Name
Last Name
3
Your Email Address* This field is required.
example@example.com
Email Verified
The verification code has been sent to some@email.com
Please check your mailbox and paste the code below to complete verification
••••
Didn't receive verification code?or
Receiving the email may take a few minutes, thank you for your patience!
4
Emergency Contact
First Name
Last Name
5
Emergency Contact Phone Number
Area Code
Phone Number
6
Health Insurance Info
Health Insurance Company Name
Policy number or ID
Group number
7
Are you 18 years of age or older?* This field is required.
YESNO
8
Since you are under 18, the next two responses must be completed by a parents or legal guardian.* This field is required.
I confirm that the person filling of the rest of this form is a parent or legal guardian
9
Release of Liability* This field is required.By checking the box below, and by entering your signature on the next page, you are waiving and releasing Campus Outreach and Tates Creek Presbyterian Church from all liability for personal injury that may happen during this trip, in accordance with the terms & conditions linked below. If you are under 18, this box must be checked by a parent or legal guardian.
10
Signature Acknowledging Release of Liability* This field is required.If you are under 18, this must be signed by a parent or legal guardian.
Clear
11
Have you tested positive for COVID-19 in the past 10 days?* This field is required.If you answered yes, please do not attend any in person events with Campus Outreach Lexington.
YESNO
12
Has anyone in your household been diagnosed with COVID-19 in the last 14 days?* This field is required.If you answered yes, please do not attend any in person events with Campus Outreach Lexington.
YESNO
13
Are you currently awaiting results from a COVID-19 test?* This field is required.If you answered yes, please do not attend any in person events with Campus Outreach Lexington.
YESNO
14
Have you been diagnosed with COVID-19 in the past 10 days?* This field is required.If you answered yes, please do not attend any in person events with Campus Outreach Lexington.
YESNO
15
Have you experienced new loss of taste and/or smell with no other explanation in the last 48 hours?* This field is required.If you answered yes, please do not attend any in person events with Campus Outreach Lexington.
YESNO
16
Have you experienced both fever (above 100.4 degrees F) and new unexplained cough associated with shortness of breath within the last 48 hours.* This field is required.If you answered yes, please do not attend any in person events with Campus Outreach Lexington.
YESNO
17
COVID Release of Liability* This field is required.By checking the box below, and by entering your signature on the next page, you are waiving and releasing Campus Outreach and Tates Creek Presbyterian Church from the risk of contracting COVID. Also, you acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that you and/or your family may be exposed to or infected by COVID-19 by attending this trip and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by COVID-19 by attending this trip may result from the actions, omissions, or negligence of myself and others, including, but not limited to, employees, other clients, and/or delivery services, (i,e UPS, USPS, FEDEX).
18
Signature Acknowledging Release of Liability* This field is required.If you are under 18, this must be signed by a parent or legal guardian.
Clear
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