Consent to Treat

Name*

First NameLast Name

Current Age*

Email*

example@example.com

Cell Phone*

Area CodePhone Number

Please read the following sections carefully: (If you are under 18 years old, your parents or legal guardian must also initial and sign this form).

Requirements: 1) Initials at the end of each section, and 2) Signature at the bottom of the form that you have read, understood and agreed to the information/statements provided.

Please note that you will be unable to participate in athletic programs at Emmaus Bible College (the “Organization”) if you refuse to initial Part I-Assumption of Risk, Release and Waiver of Liability, and Indemnity, and/or Part II - Medical Consent.

PART I - ASSUMPTION OF RISK, RELEASE AND WAIVER OF LIABILITY, AND INDEMNITY

In consideration of being permitted to participate in athletic programs at the Organization, I, the undersigned, hereby agree as follows:

I hereby acknowledge and agree that I understand the nature of the athletic programs that I will be participating in at the Organization; I am aware that there are certain risks and dangers associated with participating in athletic programs at the Organization, including risks of illness, injury, and death; and I knowingly and voluntarily accept and assume responsibility for all such risks and dangers that could arise out of, or occur during, my participation in athletic programs at or through the Organization, even if such risks and dangers arise in whole or in part from the negligence of the Organization and/or its employees, agents, and representatives, including, without limitation, any of the Organization’s athletic trainers or those contracted to provide athletic training services.

I hereby warrant that I am qualified, in good health, and in proper physical condition to participate in athletic programs at the Organization.

I hereby release and forever discharge the Organization and their respective past, present, and future officers, directors, partners, shareholders, members, managers, agents, employees, successors, subsidiaries, parents, assigns, representatives, attorneys, affiliates, heirs and insurers, from any and all liability, loss, damages, costs, claims and/or causes of action resulting from any accident, illness, bodily harm, personal injury, death, and/or property loss, however caused, arising from or in any way related to my participation in athletic programs at or through the Organization, including losses caused in whole or in part by the negligence of the Organization or any of their respective employees, agents or representatives. Further, and to the same extent and scope, I release said parties from any claim whatsoever that may be attributable to the receipt of first aid or other medical treatment rendered to me in connection with my participation in athletic programs.

I hereby agree to indemnify and hold harmless the Organization and their respective past, present, and future officers, directors, partners, shareholders, members, managers, agents, employees, successors, subsidiaries, parents, assigns, representatives, attorneys, affiliates, heirs and insurers, from any and all claims, demands, lawsuits, liabilities, damages, expenses (including reasonable attorney fees), and/or costs arising out of or related to my participation in athletic programs.

I have read this Assumption of Risk, Release and Waiver of Liability, and Indemnity Agreement in its entirety and understand and agree to its terms. Initial*

PART I - ASSUMPTION OF RISK, RELEASE AND WAIVER OF LIABILITY, AND INDEMNITY

In consideration of being permitted to participate in athletic programs at the Organization, I, the undersigned, hereby agree as follows:

I hereby acknowledge and agree that I understand the nature of the athletic programs that I will be participating in at the Organization; I am aware that there are certain risks and dangers associated with participating in athletic programs at the Organization, including risks of illness, injury, and death; and I knowingly and voluntarily accept and assume responsibility for all such risks and dangers that could arise out of, or occur during, my participation in athletic programs at or through the Organization, even if such risks and dangers arise in whole or in part from the negligence of the Organization and/or its employees, agents, and representatives, including, without limitation, any of the Organization’s athletic trainers or those contracted to provide athletic training services.

I hereby warrant that I am qualified, in good health, and in proper physical condition to participate in athletic programs at the Organization.

I hereby release and forever discharge the Organization and their respective past, present, and future officers, directors, partners, shareholders, members, managers, agents, employees, successors, subsidiaries, parents, assigns, representatives, attorneys, affiliates, heirs and insurers, from any and all liability, loss, damages, costs, claims and/or causes of action resulting from any accident, illness, bodily harm, personal injury, death, and/or property loss, however caused, arising from or in any way related to my participation in athletic programs at or through the Organization, including losses caused in whole or in part by the negligence of the Organization or any of their respective employees, agents or representatives. Further, and to the same extent and scope, I release said parties from any claim whatsoever that may be attributable to the receipt of first aid or other medical treatment rendered to me in connection with my participation in athletic programs.

I hereby agree to indemnify and hold harmless the Organization and their respective past, present, and future officers, directors, partners, shareholders, members, managers, agents, employees, successors, subsidiaries, parents, assigns, representatives, attorneys, affiliates, heirs and insurers, from any and all claims, demands, lawsuits, liabilities, damages, expenses (including reasonable attorney fees), and/or costs arising out of or related to my participation in athletic programs.

I have read this Assumption of Risk, Release and Waiver of Liability, and Indemnity Agreement in its entirety and understand and agree to its terms. Participant Initial* Parent/Guardian Initial*

PART II – MEDICAL CONSENT

I authorize the Organization’s certified athletic trainers, or contracted certified athletic trainers, to provide me with any preventative, first-aid, rehabilitative, or emergency treatment deemed necessary to my health and well-being as a result of injuries or other medical conditions occurring as the result of or during athletic programs at or through the Organization.

I give permission for my medical information to be released and discussed with the athletic training staff, Organization nurses, team coaches, strength coaches, athletic administrators, faculty representatives, the student/participant insurance coordinator, medical clinics, hospitals, medical transporters, other health care providers attending to my care, parents and/or guardians.

If reasonably necessary to provide the care described in the preceding paragraphs, I grant permission to the Organization officials or contracted certified athletic trainers to authorize my admission to a hospital or other facility that provides said treatment.

I have read this Medical Consent in its entirety and understand and agree to its terms. Initial*

PART II – MEDICAL CONSENT

I authorize the Organization’s certified athletic trainers, or contracted certified athletic trainers, to provide me with any preventative, first-aid, rehabilitative, or emergency treatment deemed necessary to my health and well-being as a result of injuries or other medical conditions occurring as the result of or during athletic programs at or through the Organization.

I give permission for my medical information to be released and discussed with the athletic training staff, Organization nurses, team coaches, strength coaches, athletic administrators, faculty representatives, the student/participant insurance coordinator, medical clinics, hospitals, medical transporters, other health care providers attending to my care, parents and/or guardians.

If reasonably necessary to provide the care described in the preceding paragraphs, I grant permission to the Organization officials or contracted certified athletic trainers to authorize my admission to a hospital or other facility that provides said treatment.

I have read this Medical Consent in its entirety and understand and agree to its terms. Participant Initial* Parent/Guardian Initial*

I understand that I have the right to revoke all or any part or the above at any time by sending written notification to the Organization’s athletic director or the Organization’s president. I understand that a revocation is not effective to the extent action has already been taken in reliance on this authorization/consent. I understand that information used or disclosed pursuant to this authorization may be subject to redisclosure by the recipient and no longer be protected by federal privacy regulations. I understand I may see and copy the information described on this form if I ask for it, and that I may get a copy of this form after I sign it. I have read and fully understand the Organization athletic program requirements and all information supplied is accurate and current to the best of my knowledge.

Participant Signature*

Date*

Date

Parent/Guardian Name*

First NameLast Name

Parent/Guardian Signature*

Date*

Date