OMP Year Round Release Form

OMP requires some basic contact and medical information. This information will not be shared unless medical treatment is saught.

PARTICIPANT INFORMATION

What group or project are you a part of?*

Participant Name*

First NameMiddle NameLast Name

Participant Phone Number*

Area CodePhone Number

Participant Email*

example@example.com

Home Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Participant Date of Birth*

Date

Years of OMP Experience*

SECTION A. EMERGENCY CONTACT INFORMATION

Emergency Contact Name*

First NameLast Name

Emergency Contact Relationship*

Emergency Contact Phone Number*

Area CodePhone Number

Alternative contact if Emergency Contact cannot be reached*

First NameLast Name

Relationship*

Phone Number*

Area CodePhone Number

SECTION B. MEDICAL INFORMATION AND TREATMENT

During an OMP Pop-Up, OMP will have staff and/or volunteers available to assist you. These individuals will make arrangements for treatment of any illness or accident that might occur during the course of the project. In the case of a more serious illness or accident, the emergency contact will be contacted as soon as possible. If the situation warrants immediate attention, you may be taken to the nearest medical treatment facility in order to ensure that you can receive needed medical treatment.

Insurance Provider*

Name on Policy*

First NameLast Name

Policy/Group Number*

Is there anything OMP would need to be aware of in case of emergency? Medications, allergies, Epi-pen, etc?*

SECTION C. CONDUCT WHILE AT OMP BUILD

Participants will not possess or use alcoholic beverages, tobacco, smoking or vaping devices, illegal drugs, and firearms/weapons. Participants will be solely responsible for your clothing, jewelry, cell phones, or other personal possessions, and OMP, its staff, and volunteers shall bear no responsibility if such items are lost, stolen, or damaged.

Participants are expected to be on their best behavior, show respect towards others as well as themselves, and follow all OMP rules and other lawful instructions. Conduct which disturbs others is improper, or is otherwise dangerous will not be tolerated and may, in the sole discretion of OMP, result in the dismissal of a participant. In such circumstances, there will be no refund of any part of any fee, if applicable.

SECTION D. TERMS AND CONDITIONS/PERMISSIONS/RELEASE
By signing this Information and Release Form I hereby:

Attendance and Participation. Grant permission for myself to attend the OMP Pop-Up and certify that I am physically capable of participating in the OMP program subject to the special medical restrictions listed above.
Damages Caused by Participant. Agree to be financially responsible for any needed repairs resulting from any damage caused by me while at the OMP Pop-Up.
Medical Treatment. (i) Authorize OMP, its staff, and/or volunteers to seek medical treatment for myself for any injury or illness incurred during OMP Pop-Up, (ii) grant permission for any physician to examine and treat, hospitalize, or secure treatment for myself in the event of an emergency, and (iii) agree to be solely responsible for the cost of any and all medical treatment (and medication) received by me.
Assumption of Risk. Acknowledge and understand that participation in the OMP Pop-Up may carry the possibility of physical illness, injury, death, and/or property damage and that I, on behalf of myself, my family members, assume the risk of such illness, injury, death and/or property damage by allowing myself to participate in the OMP Pop-Up.
Waiver, Release, Discharge, and Hold Harmless. (i) Agree on behalf of myself and my family members, to waive, release, discharge, and hold harmless OMP and any related agency, conference, district, local church, church member or attendee, employee, volunteer, or agent of OMP, from any and all liability, actions, causes of actions, claims or demands for personal illness or injury, death or property damage of any kind or nature, and any other claims whatsoever arising out of, or in any way connected with my participation in OMP Camp, (ii) Understand this waiver, release, discharge and hold harmless shall extend to all claims of every kind or nature whatsoever, foreseen or unforeseen, known or unknown, and (iii) Acknowledge that this waiver, release, discharge and hold harmless shall serve as an assumption of risk, waiver, release, discharge and hold harmless for myself, my family, and our heirs, executors, administrators, guardians or anyone else who might assert a claim on myself.
Use of Image. Consent to OMP staff and/or volunteers taking photographs, movies, or videotapes of me for OMP purposes. This consent also includes the right to edit, use and reuse said products for any and all OMP purposes, including but not limited to educational and ministry services, and advertising or marketing efforts, and release any and all rights, title, and interest I may have in said photographs, movies, videos, finished pictures, reproductions, copies or negatives of the same in connection with such uses.
Dispute Resolution. This Release Form shall be governed by and construed in accordance with the laws of the State of Arkansas exclusively, and any and all claims arising from and/or related to this agreement may only be brought in a state court located in Pulaski County, Arkansas.

BY SIGNING BELOW, I give permission for myself named above to participate in all programs and activities of OMP. In consideration for allowing the participation of myself in all programs and activities of OMP, I hereby consent to this form, including any Release of Liability above, on behalf of myself, and agree that this form shall be binding upon me, my family, heirs, legal representatives, successors, and assigns.

Parent and/or Participant Signature

OMP Participant Release Form