Adult Consent, Release, & Authorization Form

Name*

First NameLast Name

Email*

example@example.com

Phone Number*

Area CodePhone Number

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Date of Birth*

Date (mm-dd-yyyy)

Food Restrictions*

Non-Food Allergies

Medications & Instructions

Chronic Conditions

Health Insurance Carrier*

Named Insured*

First NameLast Name

Policy/Group Number*

Advanced Directive or Healthcare Power of Attorney?*

YesNo

Healthcare Representative Name*

First NameLast Name

Healthcare Representative Phone Number*

Area CodePhone Number

Emergency Contact 1*

First NameLast Name

Emergency Contact 1 Phone Number*

Area CodePhone Number

Emergency Contact 2

First NameLast Name

Emergency Contact 2 Phone Number

Area CodePhone Number

I grant SOUTHWEST HILLS BAPTIST CHURCH my permission to use photos of me taken at Southwest Hills or at a Southwest Hills event for any legal use, including but not limited to: publicity, copyright purposes, illustration, advertising, and web content. Furthermore, I understand that no royalty, fee, or other compensation shall become payable to me by reason of such use.*

Yes, I grant permission to Southwest Hills Baptist Church to use photos of myself for the above stated uses.No, I do not grant permission to Southwest Hills Baptist Church to use photos of myself.

Adult Consent, Release, & Authorization

I hereby voluntarily consent to participate in any event(s) associated with SOUTHWESTHILLS BPATIST CHURCH to travel with other participant(s) in connection with my participation in such event(s).

I hereby further release, indemnify and hold harmless SOUTHWEST HILLS BAPTIST CHURCH of Beaverton, OR, together with its staff, employees, authorized representatives and other event participants from any and all liability for injuries, claims, demands or damages, known and unknown, whether for physical or mental injury, or illness, or property damage, that may result my participation in the event(s) listed above, or travel to or from said event(s), during the dates indicated, EXCEPT for conduct of said persons that is willful, wanton, or grossly negligent.

In the event of an injury, damage, or other medical emergency whereby I am unable to make medical decisions on my own, I hereby consent to administration of emergency care and treatment, x-ray examination, diagnosis and/or hospitalization for me; PROVIDED, HOWEVER, that such emergency care is, in the professional judgement of a duly licensed physician, surgeon, nurse, EMT or dental professional, reasonably necessary to avoid life-threatening or irreparable injury, harm, or damage. OTHERWISE, it is hereby agreed and understood that consent to such emergency care and treatment, x-ray examination, diagnosis and/or hospitalization is given only after making reasonable efforts to contact my spouse, family or designated health care representative by telephone or otherwise so as to allow them to consent directly to such emergency treatment. In the event the subject activity is being conducted at a remote location where access to medical care and treatment is not readily available, I understand and accept the risks and delays inherent to and associated with obtaining medical care and treatment in such remote locations.

Subject to the foregoing, I further understand and agree that my insurance carrier, if any, and I assume full responsibility for payment of any and all reasonable and necessary costs and expenses related to such emergency treatment and hereby indemnify and hold harmless SOUTHWEST HILLS BAPTIST CHURCH of Beaverton, OR, together with its staff, employees, authorized representatives and other event participants, from such costs and expenses.

I understand that SOUTHWEST HILLS BAPTIST CHURCH believes that the Bible commands them to make every effort to live at peace and to resolve disputes with each other in private or within the Christian church (see Matthew 18:15-20; 1 Corinthians 6:1-8). Therefore, the parties agree that any claim or dispute arising from or related to this agreement shall be settled by biblically-based mediation and, if necessary, legally binding arbitration, in accordance with the Rules of Procedure of Peacemaker Ministries of Billings, Montana.

I have read and understood this form in its entirety, and I have signed the same voluntarily and not under duress or other compulsion. By my signature, I hereby intend to bind my heirs, successors, representatives, administrators and assigns. I further represent that the information provided herein is true, complete and accurate to the best of my knowledge and belief.

Acknowledgement*

I acknowledge the above.

Signature*

This digital signature is legally binding.

Today's Date*

Date (mm-dd-yyyy)

Are you 21 or older?*

YesNo

Parent/Guardian Signature (if participant is under 21)*

This digital signature is legally binding.

Today's Date*

Date (mm-dd-yyyy)