Liability Waiver | GroupVitals | Archdiocese of St. Paul and Minneapolis

Adult Liability Waiver

Each adult participant, volunteer, driver, group leader and chaperone, must sign this form.

Duration

Entire time I participate in a parish small group.*

RELEASE OF LIABILITY, INDEMNIFICATION AGREEMENT & MEDICAL RELEASE

I, agree on behalf of myself, my heirs, assigns, executors, and personal representatives, to hold harmless, and defend my Parish, the Archdiocese of Saint Paul and Minneapolis, its officers, directors, agents, employees and representatives ("Releasees") associated with the Parish Small Group I will be participating in from any and all liability claims, injury, loss and damage arising from or in connection with my participation in the Parish Small Group I will be participating in.

Further, I AGREE to hold Releasees harmless and indemnify Releasees for any claim or cause of action whatsoever, including but not limited to all claims relating to communicable disease, arising out of the above Parish Small Group I will be participating in which takes place during the above identified dates that is brought against Releasees by myself or my family members, heirs, assigns, executors, and personal representatives.

I UNDERSTAND that participation in the described activity involves danger and risk of injury. The inherent danger is understood and voluntarily assumed.

Emergency Medical

In case of emergency:

If I should require medical treatment and I am not able to communicate my desires to attending physicians or other medical personnel, I give permission for the necessary emergency treatment to be administered. *

Allergies and/or other health conditions: *

Emergency Contact

In case of an emergency and for permission for treatment beyond emergency procedures, please contact:

Full Name *

Relationship to me *

Daytime Phone *

Night-time Phone

Health Insurance Carrier

Insurance ID Number

Insurance Policy Number

Digital Signature

By completing this form and supplying your name and email you are digitally signing this waiver.

I HAVE READ THIS DOCUMENT. I UNDERSTAND IT IS AN AUTHORIZATION FOR MEDICAL TREATMENT, INDEMNIFICATION AGREEMENT AND RELEASE OF ALL CLAIMS. I UNDERSTAND I ASSUME ALL RISK INHERENT IN THIS ACTIVITY. I VOLUNTARILY SIGN MY NAME EVIDENCING MY ACCEPTANCE OF THESE PROVISIONS. *

First Name *

Last Name *

Email *