STS. PETER & PAUL
2160 California Crossroads
California, Kentucky 41007
Emergency Medical Release & Liability Waiver
Applicant/Participant’s General Information
Name______________________________________________________ Birthdate_______________
Street Address_____________________________________________________
City ______________________________ State______________________ Zip_________________
Minor Applicant/Participant’s Parental/Guardian Information
Father's Name_______________________Home Phone (_____)__________
Bus Phone (_____)________________
Mother's Name______________________ Home Phone (_____)__________
Bus Phone (_____)___________________
In an emergency when parent/guardian cannot be reached, please contact the following:
Name_____________________________ Home Phone (_____)__________
Bus Phone (_____)__________________
Name_____________________________ Home Phone (_____)__________
Bus Phone (_____)__________________
TREATMENT FOR INJURY WILL BE BASED ON INFORMATION PROVIDED HEREIN.
Allergies_____________________________________________________________________________________
Other Medical Conditions________________________________________________________________________
Physician_________________________ Home Phone (_____)____________
Bus Phone (_____)_________________
Medical/Hospital Insurance Company______________________________________
I the undersigned applicant/participant (if applicant/participant is 18 years of age or older) or undersigned parent/guardian of the above listed minor applicant/participant acknowledge and fully understand each of the following:
1. That each applicant/participant may be engaging in activities that involve risk of serious injury, including permanent disability or death, and severe social and economic losses which might result not only from their own actions, inactions or negligence, but action, inaction or negligence of others, that there may be other unknown risks not reasonably foreseeable at this time.
2. I assume all the foregoing risk and accept personal responsibility for the damages following such injury, permanent disability or death.
3. I hereby release, discharge, covenant not to sue and/or otherwise indemnify Sts. Peter & Paul, its affiliated organizations and sponsors, their managers, employees and associated personnel, officers, directors, agents, including the owners and leasers of premises, all of which are hereinafter referred to as 'releasees', from any and all liability to each of the undersigned, his/her heirs or next of kin for any and all against any claim by or on behalf of the applicant/participant as a result of the applicant's participation in the use of the Sts. Peter & Paul facility..
4. I also agree to save and hold harmless and indemnify each and all parties herein referred to above as releasees from all liability, loss, cost, claim or damage whatsoever, including death or damage to property, which may be imposed upon said releasees because of any defect in or lack of such capacity to so act or caused or alleged to be caused in whole or in part by the negligence of the releasees.
I HAVE READ THIS AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND HAVE SIGNED IT FREELY AND WITHOUT ANY INDUCEMENT OR ASSURANCE OF ANY NATURE AND INTEND IT TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE GREATEST EXTENT ALLOWED BY LAW AND AGREE THAT IF ANY PORTION OF THIS AGREEMENT IS HELD TO BE INVALID THE BALANCE, NOTWITHSTANDING, SHALL CONTINUE IN FULL FORCE AND EFFECT.
Applicant/Participant Signature_________________________________________
Date______________________
Parent/Guardian Signature_____________________________________________
Date______________________
