VICTORY KIDS - PARTICIPATION AGREEMENT

PARTICIPANT INFORMATION (to be completed by the authorized guardian, if participant is a minor)

Description of activity *

Date(s) of activity *

Location(s) of activity *

Participant's First Name *

Participant's Last Name *

Name of Parent(s) / Guardian(s) *

Street Address *

City *

State *

Zip Code *

Emergency contact phone (day) *

Emergency contact phone (evening) *

Parent / Guardian's Email Address *

Are there any specific or special medical needs that we should be aware of for Participant? *

Yes

No

Special Medical Needs
Please list any special needs below, along with any information that could be helpful. *

Is sponsor authorized to approve medical treatment? *

Yes

No

Is participant covered by personal/family medical insurance? *

Yes

No

Name of insurer *

Policy or group number *

Participation Agreement

*

I acknowledge that participation in the activity described above involves risk to the Participant (and Participant's parents or guardians, if Participant is a minor), and may result in various types of injury including, but not limited to, the following: sickness,bodily injury, death, emotional injury, personal injury, property damage and financial damage.

In consideration for the opportunity to participate in the activity described above (the "Activity"). The Participant (or parent/guardian if Participant is a minor) acknowledges and accepts the risks of injury of injury associated with Participation in and transportation to and from the Activity. The Participant (or parent/guardian accepts personal financial responsibility for any injury or other loss sustained during the activity or during transportation to and from the activity, as well as for any medical treatment rendered to the Participant that is authorized by the sponsor or its agents, employees, Volunteers, or any other representatives (collectively referred to hereinafter as the "Activity Sponsor "). Further, the Participant (or parent/Guardian) releases and promises to indemnify, defend and hold harmless the Activity Sponsor for any injury arising directly or indirectly out of the described Activity or transportation to and from the Activity, whether such injury arises out of the negligence of the Activity Sponsor, the Participant or otherwise.

If a dispute over this agreement or any claim for damages arises, the Participant (or parent/guardian) agrees to resolve the matter through a mutually acceptable alternative dispute resolution process. If the Participant (or parent/guardian) and the Activity Sponsor cannot agree upon such a process, the dispute will be submitted to a three-member arbitration panel for resolution pursuant to the rules of the American
Arbitration Association.

Signature of Participant or Parent/Guardian (if participant is a minor) *

clear