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IMPACT CHURCH

Release of Liability and Medical Consent – 2024 Events and Activities


Consent and Acknowledgement

By affixing my signature below, I attest that the statements made are true, complete, and correct, including but not limited to the medical information disclosed below, and that I am the custodial parent or legal guardian of all minor dependents listed on this form as members of my household. I understand that certain events sponsored by Impact Church of Jacksonville, Inc. (hereinafter, “Impact Church”) involve activities that are strenuous in nature and could have adverse impact on individuals with certain medical physical and/or emotional conditions. I further acknowledge that I understand the statements contained and information provided in this form by me will be relied upon by Impact Church in determining whether I and/or my minor dependents will be eligible to participate in certain events. I warrant that I and all my minor dependents will conduct ourselves in such a manner that will reduce or negate potential harm/injury to ourselves or any other person or property at any and all events and activities in which we participate. If, through my actions or the actions of my minor dependents, harm or injury should occur to another’s person and/or property, I hereby accept full responsibility for such, and Impact Church assumes no duty to indemnify me or any other person or entity involved, and I also hereby agree to indemnify and hold harmless Impact Church against any and all claims, liabilities, and costs (including, but not limited to, actual legal fees and expenses) of any nature arising directly or indirectly from my actions and my child’s actions. For purposes of this document, Impact Church includes Impact Church of Jacksonville, Inc., its subsidiaries and related organizations, and its agents, including its officers, its trustees, its employees, and its volunteer leaders.

Additionally, if any charges incurred by me or my minor dependent associated with events described herein are not paid in full by me and those charges are billed to Impact Church, I hereby agree and acknowledge that I am responsible and will pay these charges personally.

Release and Waiver of Liability

Please be advised that this consent form waives specific legal rights that you may have in connection with injuries or events arising out of your or your minor dependent’s participation in Impact Church sponsored programs that take place in calendar year 2024.

I hereby authorize Impact Church (including its agents) to act for me according to their best reasonable judgment in an emergency requiring medical attention to me, in the event that I am incapacitated, or to my minor dependent in my absence, and I hereby release, exonerate, and discharge Impact Church from any and all actions or causes of action known or unknown resulting from injuries incurred from participation in events it conducts.

By my signature below I acknowledge that I have read this form and that I understand I am waiving specific legal rights I might otherwise have against Impact Church, its subsidiaries and affiliates, its officers, its trustees, its employees, and/or its volunteers.

Knowing all these things, it is my desire and intent to waive any and all causes of action that I might have against Impact Church and its subsidiaries and affiliates, officers, trustees, employees, and/or volunteers for any liability whatsoever arising out of participation in any event conducted during calendar year 2024.

Transportation Liability Waiver

By signing this form, you are giving up specific legal rights you may have. Please read carefully.

I/We understand that Impact Church is providing transportation to certain of its scheduled events. In the normal course of motor travel, accidents can occur. These accidents are sometimes the fault of others and sometimes the fault of the driver of the vehicle in which I/we are riding. Knowing all of the above, I/we and my/our minor dependents hereby waive any claim or cause of action against Impact Church, its officers, its trustees, its employees, and/or its volunteers for any injury or damage that may occur arising out of transportation being provided by Impact Church relating to any of its sponsored events. I understand that this waiver shall be binding upon me, my personal representatives, heirs, and assigns forever. I have read all the above and fully understand its meaning, and I have signed this waiver voluntarily.

Medical Consent Form

(If necessary, please attach additional sheet to complete answers to this section)

If I/we fail to inform Impact Church in writing of any diseases or other health related matters including but not limited to exposure to any communicable disease, medical history, potential side effects of conditions or medications, or any and all other information regarding my/our health or that of my/our minor dependents and, as a result of such failure to disclose, members of my household, other individuals, and/or property is damaged or injured in any way (including death), I/we hereby release Impact Church, its affiliates, its trustees, its officers, its employees, and/or its volunteers from any damages, lawsuits or other financial burdens which may arise from my failure to disclose such information.

Date: April 26, 2024



First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Insurance

Insurance Carrier*

Insurance Policy Number*
Medical disclosure:
1. Allergies or reactions?*
No
Yes
2. Sinus problems or headaches?*
No
Yes
3. Frequent skin rashes?*
No
Yes
4. Convulsions/seizures?*
No
Yes
5. Heart trouble?*
No
Yes
6. Diabetes?*
No
Yes
7. Frequent colds, sore throats, ear aches*
No
Yes
8. Trouble with passing urine or bowel moves?*
No
Yes
9. Shortness of breath, asthma?*
No
Yes
10. Speech, vision, or auditory problems?*
No
Yes
11. Menstrual problems?*
No
Yes
12. Dental problems?*
No
Yes

If Yes, date of last exam:
13. Now receiving or under observation for mental, nervous or psychological condition*
No
Yes
14. Symptoms of bronchitis, emphysema, or respiratory system disorders*
No
Yes
15. Exposed to any communicable disease?*
No
Yes
16. Other?*
No
Yes

Please explain any problem areas identified above and to whom they apply:
Should any child's activity be restricted because of any physical defect or illness?*
No
Yes
Activities that should be restricted:
Swimming pool
Competitive sports
Food
Amusement rides

Please explain degree and/or type of restrictions:

Household members who wear glasses:

Household members who wear contacts:

Children's immunizations - date of most recent booster:


Polio:

Mumps:

Diphteria:

Tetanus:

Pertussis:

Measles:

Rubella:
I, hereby authorize leader(s) of any and all Impact Church sponsored events to obtain in their reasonable discretion any necessary Emergency Medical Services for the minor dependents named in this document during the periods of their attendance at such sponsored events. I hereby waive and otherwise give up any claim of liability I may have against Impact Church Inc., its subsidiaries and related organizations, and its agents, including its officers, its trustees, its employees, and its volunteer leaders which might arise in the course of their reasonable attempt to obtain Emergency Medical Treatment. I also agree to be responsible for any and all charges which might be incurred by Impact Church for obtaining emergency treatment which it reasonably deems necessary in caring for my participating minor dependents, regardless of whether or not the participant is covered by a health insurance plan.


By signing below the Parent or Court-Appointed Legal Guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Signature*
Electronic Signature Consent*
 By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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