• MEXICO Missions Trip- Young Adults

    Medical, Permission, Liability Release, and Indemnification Agreement Form

  • Please take a few moments to carefully complete the form. Each section is required unless otherwise specified.

  • Participant's Information

  • Today's Date
     - -
  • Date of Birth:*
     - -
  • Format: (000) 000-0000.

  • In case of emergency, notify:

  • PRIMARY EMERGENCY CONTACT

  • Format: (000) 000-0000.

  • SECONDARY EMERGENCY CONTACT

  • Format: (000) 000-0000.

  • Participant's Medical Information

  • Format: (000) 000-0000.
  • Allergies?
  • Any health conditions?
  • Check all that apply

  • Participation

  • The participant knows how to swim*
  • The participant may take part in all activities*
    • PERMISSION, LIABILITY RELEASE, AND INDEMNIFICATION AGREEMENT FOR GRACE CHAPEL (tap to expand) 

    • MEDICAL AUTHORIZATION AND INSURANCE COVERAGE
      The health information on the front of this form is correct, to the best of my knowledge. In the event the emergency contact cannot be reached in an emergency, I HEREBY GIVE PERMISSION to the physician selected by GRACE CHAPEL, to hospitalize, to secure proper treatment, to order injection, anesthesia, and/or surgery for participant named below. I GIVE PERMISSION for GRACE CHAPEL to provide for the participant a certified First Aid provider to administer First Aid and over the counter medication as needed for illness or injury.

      I AGREE that photocopies of this complete form are to be considered legally valid and binding for trips both on and off the church property. I AGREE to obtain and maintain personal insurance covering the participant in the program with an appropriate waiver of subrogation rights to reflect the fact that the participant's personal insurance shall supersede and be used before any insurance coverage that may be provided by Grace Chapel. In the absence of the aforementioned insurance, I AGREE to pay all costs of rescue and/or medical services as may be incurred by the participant.
      ASSUMPTION OF RESPONSIBILITY
      I AGREE to assume full responsibility for the participant's actions and their consequences during his/her participation in all programs at Grace Chapel including without limitation: any injury to the participant and/or property or any inconvenience resulting therefore or from any other circumstance related to such action.
      PERMISSION FOR PARTICIPATION, TRANSPORTATION, AND PROMOTION
      I GRANT PERMISSION for the participant to engage in all Grace Chapel activities, and to be transported by a Grace Chapel staff member who is a legally licensed driver, on all activities sponsored by Grace Chapel, both on and off the church property. I GRANT PERMISSION for Grace Chapel to use pictures of the participant taken while in their care and quotations from evaluations, letters, or interviews relating to the program experience for promotion and commercial purposes.
      LIABILITY RELEASE AND INDEMNIFICATION AGREEMENT
      - GRACE CHAPEL and the undersigned agree that the Activity poses risks including the following specific risks: Physical injuries, including injuries to one or more parts of the body which are of a permanent nature, and injuries which result in paralysis, coma, or death, as well as similar and dissimilar risks (herein the "Risks").
      - For and in consideration of GRACE CHAPEL allowing the undersigned's participant to participate in the Activity, and other good and valuable consideration the receipt and sufficiency of which is hereby acknowledged, the undersigned for himself/herself, his/her participant and his/her participant's personal representatives, assigns, heirs, distributes, guardians and next of kin (herein the
      "Releasers"), hereby irrevocably and unconditionally releases, waives, discharges, and covenants not to sue GRACE CHAPEL and its affiliates, subsidiaries, divisions, members, directors, officers, employees, volunteers and agents (herein the "Releasees"), for and from all claims of any nature now or hereafter existing whether known or unknown, including but not limited to, all liability to the Releasers, on account of injury to the undersigned or injury to the property of the undersigned, whether caused by the negligence of Releasees or otherwise, while the undersigned is participating in the Activity.
      - The undersigned is fully aware of the Risks and other hazards inherent in the Activity, and voluntarily assumes the Risks and all other risks or loss, damage, or injury that may be sustained by the undersigned while participating in the Activity. The undersigned understands that with any trip there are risks, hazards and possible dangers. The undersigned also understands that these risks,
      hazards and dangers are further increased when other persons, whether or not of the same level of experience or skill, are present at the same time and using the same facilities.
      - I, individually and on behalf of my minor participant, and in consideration of my participant being permitted to participate in events with GRACE CHAPEL, FURTHER AGREE TO INDEMNIFY AND HOLD HARMLESS the Releasees and all other persons acting in any capacity on their behalf, from any and all claims or demands which are brought by or on behalf of the participant, and which are in any way connected with such participation by the participant and arising out of or in consequence of the Activities and/or the participant's actions.
      The undersigned warrants that he or she has fully read and understands this Liability Release Agreement and voluntarily signs the same, and that no oral representations, statements or inducements apart from the foregoing written agreement have been made to the undersigned.

      Grace Chapel is a California non-profit religious corporation

    • ACKNOWLEDGMENT AND ACCEPTANCE (tap to expand) 

    • ACKNOWLEDGMENT AND ACCEPTANCE (PLEASE READ SECTIONS ABOVE CAREFULLY BEFORE SIGNING BELOW):

      I acknowledge that I have read and understand the terms and conditions in the sections above and agree to them. I certify that the information provided is accurate and complete.
    • Date Signed:*
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  • Should be Empty: