PARTICIPANTS NAME: 

DATE OF BIRTH:

SEX: 

GRADE: 

ALLERGIES:

MEDICATIONS: 

PARENT(S) NAME: 

PARENTS HOME #: 

PARENTS CELL #: 

PARENT EMAIL: 

PARTICIPANTS CELL #: 

SPORT: 

PHYSICIANS NAME:

PHYSICIANS #: 

Please list the following from your medical insurance card: 

Insurance Company Name/Phone 

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AGAPE OUTREACH MINISTRIES/AGAPE FAITHWORKS 
Waiver and Release of Liability
Basketball / Volleyball/Track
READ BEFORE SIGNING

By signing this agreement, I am allowing my child(ren) to participate in any way at Agape Faithworks HEG located at Immanuel Bible Church 1244 W Farms road Howell NJ 07731, athletic sports program, related events and activities either at the address above or offsite and acknowledge, appreciate, and agree that:

1) The risk of injury to my child/ward, myself, from the activities involved in these programs is significant, including the potential for permanent disability, paralysis and death, and while particular rules, equipment, and personal discipline may reduce this risk of serious injury does exist; and,
2) FOR MYSELF, SPOUSE, AND CHILD(REN) I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES or others, and assume full responsibility of child(ren), participation; and,
3) I willingly agree to comply with the stated and customary terms and conditions for participating.  If, however, I observe any unusual significant concern in my child(rens)’, readiness or, hazard during my presence or participation, and/or in the program itself, I will remove my child(ren), from participating and bring such to the attention of the nearest official immediately; and,
4) I, for myself, my spouse, my child(ren), and on behalf of my/our heirs, assigns, personal representatives and next of kin, HEREBY RELEASE, INDEMNIFY, AND HOLD HARMLESS Agape Outreach Ministries dba Agape Faithworks HEG, their officers, directors, officials, volunteers, agents, and/or employees, other participants, sponsoring agencies, tournament host, sponsors, advertisers, and if applicable, owners and lessors of premises used to conduct the event (“Releasees”), WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH, or loss or damage to person or property, incident to my child(ren), involvement or participation in these programs, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE, TO THE FULLEST EXTENT PERMITTED BY LAW.

I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.

PARENT/GUARDIAN SIGNATURE:

DATE SIGNED: 

UNDERSTANDING OF RISK
I understand the seriousness of the risks involved in participating in this program, my personal responsibilities for adhering to rules and regulations, and accept them as a participant.

PARTICIPANTS SIGNATURE: