Name of Event

Participant #1 Name

First Name

Last Name

Participant #2 Name

First Name

Last Name

Participant #3 Name

First Name

Last Name

Participant #4 Name

First Name

Last Name

Participant #5 Name

First Name

Last Name

Parent/Guardian Name

Required if any participant is under the age of 18

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Emergency Contact Name

First Name

Last Name

Emergency Contact Phone

(###)

###

####

Does the participant have any allergies or medical conditions?

If none, please type "None" in the box below.

PARTICIPATION AGREEMENT

By clicking "Submit" below, I acknowledge that participation in the activity described above involves risk to the Participant (and to 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 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 Philadelphia Baptist Church 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 and the activity sponsors 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.

Philadelphia Baptist Church

Philadelphia Baptist Church

PBC Activity Participation Agreement