Child's Name *

First Name

Last Name

Child's Date of Birth *

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Parent/Guardian 1 Name *

First Name

Last Name

Parent/Guardian 1 Best Phone Number *

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Parent/Guardian 1 Secondary Phone Number *

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Parent/Guardian 1 Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent/Guardian 2 Name

If Applicable

First Name

Last Name

Parent/Guardian 2 Best Phone Number

If Applicable

(###)

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Parent/Guardian 2 Secondary Phone Number

If Applicable

(###)

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Parent/Guardian 2 Address

If Applicable

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Primary Emergency Contact *

First Name

Last Name

Primary Emergency Contact Best Phone Number *

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Primary Emergency Contact Secondary Phone Number *

(###)

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Primary Emergency Contact Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Secondary Emergency Contact *

First Name

Last Name

Secondary Emergency Contact Best Phone Number *

(###)

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Secondary Emergency Contact Secondary Phone Number *

(###)

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Secondary Emergency Contact Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Physician's Phone Number *

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Date that form was electronically signed *

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Conditions *

IMPORTANT: Please read all sections carefully and check off EACH AND EVERY check box when you have agreed to them.

1. GENERAL RELEASE: I/We on behalf of myself/ourselves and the Participant, release, protect, indemnify, forever discharge, and hold harmless RRUMC and its directors, officers, employees, volunteers, agents, successors and assigns from any and all liability, claims, demands, actions, costs, expenses, damages, defenses, or causes of action of whatever nature, kind, or description, known or unknown, either in law or in equity, now existing hereafter acquired, from Participant's activities with RRUMC. This release includes, but is not limited to, all losses and damage of any kind to property or personal injury (including death), based upon any activity, accident, incident, or occurance arising out of, incidental to, or in any way resulting from my participation in RRUMC activities or ministries, even is caused by the strict liability or negligence (whether sole, joint, or concurrent) of RRUMC and whether asserted by me or any person claiming by, through, or under me.

2. MEDICAL RELEASE: I understand and acknowledge that RRUMC does not assume any responsibility for or obligation to provide financial assistance or other assistance in the event of injury or illness. I understand and acknowledge that RRUMC does not carry or maintain health, medical, or disability insurance coverage for any participant.

3. MEDIA RELEASE: I further irrevocably grant to RRUMC, its assigns and successors, my consent and full right to: use Participant's name, photograph, likeness, image, voice and biography in any and all media, publications, advertising, and publicly, in connection with Participant's participation hereunder.

4. STANDARDS OF CONDUCT: I/We agree that Participant will comply with all laws and ordinances and with RRUMC's rules, standards, and instructions for behavior for RRUMC activities and ministries and agree that RRUMC has the right to enforce standards of conduct, in its sole judgment.

5. GENERAL PROVISIONS: I expressly agree that this Release is intended to be as broad and inclusive as permitted by the laws of the state of Ohio, and that this Release shall be governed by and interpreted in accordance with the laws of the state of Ohio. I agree that in the event that any clause of provision of this Release shall be held to be invalid by any court of competent jurisdiction, the invalidity of such clause or provision shall not otherwise affect the remaining provisions of this Release, which shall continue to be enforceable. The headings contained in this Agreement are for reference purposes only and shall not affect in any way the meaning or interpretation hereof.

Parent/Guardian 1 Signature *

This is your electronic signature for this form. By typing your name in this box, you are agreeing to the above conditions for the Participant.

First Name

Last Name

Parent/Guardian 2 Signature (If Applicable)

This is your electronic signature for this form. By typing your name in this box, you are agreeing to the above conditions for the Participant.

First Name

Last Name

Date That Form Has Been Electronically Signed *

Please select the date for which you are filling out and electronically signing this form.

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