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Galveston FBC
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Galveston FBC Youth Activity Participation Agreement
Name of Participant(s)
Name of Parent/Guardian
Address
Phone
Emergency Contact Name
Emergency Contact Phone
List of Allergies or Medical Conditions
Is sponsor authorized to approve medical treatment?
Yes
No
Is participant covered by personal/family medical insurance?
Yes
No
Name of Insurer (if applicable)
Insurance Policy/Group Number (if applicable)
Name of Organization Sponsoring Group
Address
Phone Number
Sponsor Coordinator
Date(s) & Location of Activity
Description of Activity
Participation Acknowledgement
I acknowledge that participation in the activity described above involves risk to the participant (and participant's parents or guardians, if the participant is a minor), and may result in various types of injury. In consideration for the opportunity to participate in the activity described above, the participant or parent/legal guardian acknowledges and accepts the risks of injury associated with participation in and transportation to and from the activity. The participant or parent/guardian accepts personal financial responsibility for any injury or other loss sustained during the activity or during transportation to and from the activity as well as any medical treatment rendered to the participant that is authorized by the sponsor or its agents, employees, volunteers, or any other representative (collectively referred to as the "activity sponsor"). Further, the participant or parent/guardian releases and promises to indemnify, defend, and hold harmless the activity sponsor for any injury arising directly or indirectly out of the described activity or transportation to and from the activity, whether such injury arises out of the negligence of the activity sponsor, the participant, or otherwise. If a dispute over this agreement or any claim for damages arises, the participant, or parent/guardian, agrees to resolve the matter through a mutually acceptable alternative dispute resolution process. If the participant or parent/guardian and the activity sponsor cannot agree on such a process, the dispute will be submitted to a three-member arbitration panel for resolution in accordance with the rules of the American Arbitration Association.
Parent/Guardian Signature (by typing name here you agree to above terms)
Submit
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