Liability Release Form

LIABILITY RELEASE FORM (Release of All Claims) In consideration for being accepted by Sacramento Hmong Alliance Church for participation in SHAY Annual Youth Rafting Trip, I do hereby release, forever discharge and agree to hold harmless Sacramento Hmong Alliance Church and the directors thereof from any and all liability, claims or demands for personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever which may be incurred by the undersigned and the participant that occurred while said person is participating in the abovedescribe trip or activity including recreation and work activities. The and agents for any liability sustained by said acts of said participants, including expenses incurred attendant thereto. The undersigned further consents to the administration of first-aid and/or doctor’s care, or any other form of medical treatment necessitated by illness or injury that may require the same. In the event of the necessity of such care or treatment as heretofore described, the undersigned agrees to hold harmless and indemnify said church, its director, employees, and agents from any acts of malfeasance, and/or failure to act on the part of those chosen to administer medical care on behalf of the participant. ___________________

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Participant Name (printed)

Participant’s Signature

Age

Date signed

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Address(street)

Signature of Parent or Legal Guardian (require if under 18) Date Signed

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_____________________________ City State Zip Code

____/___________________ Home Phone #

____/____________________ Work/Cell Phone #

_______________________ Participant’s Insurance Company

_________________________ Emergency Contact

____/____________________ Emergency Phone #

_______________________ Policy Number Please circle one: Swimmer / Non-Swimmer List All Allergies: ___________________________________________________________________________ List Medical Condition & Medications: __________________________________________________________ Anything else we need to know: ________________________________________________________________

One Form Per Person