Medical & Liability Release for Adults 2026
  • MEDICAL INFORMATION and ASSUMPTION OF RISKS/LIABILITIES WAIVER FORM FOR ADULT 2026

  • PARTICIPANT

    (write name as listed on license/passport)
  • Gender
  • Format: (000) 000-0000.
  • Birthdate
     / /
  • EMERGENCY CONTACTS

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • DOCTOR AND HEALTH INSURANCE

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • HEALTH CONDITION OF PARTICIPANT

  • Check if Applicable:
  • Allergies:
  • Food Restrictions:
  • Activity Restrictions:
  • Epi-Pen Needed:
  • Date of last tetanus
     / /
  • PURPOSE OF LIABILITY WAIVER AND ASSUMPTION OF RISKS AGREEMENT

    Valley Church Children and Youth Ministries (the "Program") is hosted by The Valley Church of Santa Clara County, Inc. (hereafter "the Church" or "Valley Church" The Program runs from January 1, 2026 to January 1, 2027. The purpose of this Assumption of Risks and Liability Waiver Agreement ("the Agreement") is twofold. First, this Agreement will inform participants of the types of risks involved in participating in the Program. Second, this Agreement sets forth the terms of the participant's assumption of the risks described in this Agreement, their waiver of liability, and their general release of the Church in exchange for the right to participate in the Program. Participants are required to fully read and sign this Agreement before the Church will allow participation in the Program. By reading and signing this Agreement, the undersigned will signify that they have been informed of and recognize the risks involved in their participation in the Program and waives any and all liability that could arise against the Church as a result of or stemming in any way from their participation in the Program.

    WAIVER OF LIABILITY AND GENERAL RELEASE

    In consideration for the Valley Church permitting me to participate in the Program, I relinquish all rights to recover damages for any and all injuries or property loss that I sustain during or en route to and from any part of the Program, waiving any liabilities, causes of action, lawsuits, claims, demands, or damages of any kinds whatsoever that I or my assignee, child, heir, distribute, guardian, next of kin, spouse, and legal representative now have, or may have in the future, for injury, death, or property damage related to (i) my participation in the Program, (ii) the negligence or other acts of any representative or agent of Valley Church, whether directly connected to Program activities or not, and however caused, or (iii) the condition of any premises where the Program's activities occur, whether or not I actively participate in the Program activities. I also agree that I or my assignee, child, heir, distributee, guardian, next of kin, spouse, and legal representative will not make a claim against, sue, or attach the property of Valley Church or its agents or representatives in connection with any of the matters covered in this Agreement.

    ACKNOWLEDGEMENT AND ASSUMPTION OF RISKS

    I am aware that my participation in the Program will include potentially dangerous physical activities, including risks inherent to engaging in different kinds of sports and physical games, outdoor activities, and dangers inherent to transit and travel. Some of the risks that I will encounter could include but are not limited to physical or psychological injury, pain, suffering, illness, disfigurement, broken bones, temporary or permanent disability (including paralysis), economic or emotional loss, and/or death. By signing below, I certify that I am aware of the risks that I will take by nature of my participation in the Program and hereby voluntarily assume and take full responsibility for all of these risks, as well as any other risk or danger that I may encounter while participating in the Program.

    CONSENT TO MEDICAL TREATMENT

    Should I suffer injury or illness that requires immediate medical attention, and I am unable to give consent, I understand that Valley Church will attempt to contact my listed emergency contacts as soon as possible. I am furthermore aware that urgency may require immediate action by Valley Church, which could include treatment by a representative of Valley Church or seeking the help of medical professionals. If it appears that serious or permanent harm could result from lack of immediate action, Valley Church and its representatives are authorized to exercise their best discretion in undertaking appropriate action to care for me, which could include giving permission and/or instruction to medical professionals. Neither Valley Church, nor its representatives, will incur any liability for having taken such action. If I suffer injury or illness that requires professional medical treatment or assistance at any point en route to, during, or returning from the Program, I will be financially responsible for the cost of such treatment or assistance. Any insurance policy of Valley Church or organization sponsoring this event may be used only as secondary coverage.

    AFFIRMATION AND SIGNATURE

    I, the undersigned, am at least 18 years of age. By signing below, I certify that I have read this Agreement and its attachments in their entirety. By signing this Agreement, I agree to be bound by its terms, waiving and releasing any liability and/or claims against Valley Church that may arise as a result of my participation in the Program.

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