OCSM Chapter Event Waiver

OCSM Chapter Event Waiver
OCSM Chapter*
Chapter Email
example@example.com
Event Name & Location*
Event Date & Time*

MonthDayYear
Date
Hour MinutesAM/PM Option

Personal & Contact Information
Student Name*

First NameLast Name
Age*
Example: 23
Student Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Parent/Guardian Name*

First NameLast Name
Phone Number*
Please enter a valid phone number.
Parent/Guardian Email*
example@example.com

Release
I, the undersigned, agree to the following liability release.

I hereby participate in the above-described activity organized by the Coptic Orthodox Metropolis of the Southern United States (“Diocese”). I fully realize that there are risks inherent in the participation in this activity and I assume all such risks. Accordingly, I, intending to be legally bound, hereby release and hold harmless the Diocese, its clergy, servants, agents and volunteers from any and all liability as a result of my participation in the activity, or any injury, loss, damage or incident occurring during my participation in the activity regardless of any negligence on the part of Diocese, its clergy, servants, agents and volunteers. Furthermore, I also grant the Diocese, its clergy, servants, agents and volunteers full authority to take whatever action it considers warranted under the circumstances for my health and safety. Specifically, in case of a situation requiring medical treatment, I authorize the Diocese, its clergy, servants, agents and volunteers, at its discretion and at my expense, to place me in a hospital for medical services and treatment, or if no hospital is available, to obtain medical service and treatment from a doctor. In obtaining, authorizing, and supervising such medical service and treatment, the Diocese, its clergy, servants, agents and volunteers shall have the discretion to act in the same manner and with the same authority as I could act. This authorization is given with the understanding that if a situation arises requiring medical treatment, the Diocese, its clergy, servants, agents and volunteers will immediately attempt to notify my parent/guardian or emergency contact person and will continue in its efforts to notify the parent/guardian or emergency contact person until it has succeeded in doing so.
Date

MonthDayYear
Date
Parent/Guardian Signature

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