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GENERAL ACKNOWLEDGEMENT  OF RISK
The Episcopal Church in Jackson Hole & Shepherd of the Mountains Lutheran Church

 

I will attend and participate in The Episcopal Church in Jackson Hole’s and Shepherd of the Mountains Lutheran's (the “Church”) activities for the calendar year 2018.

I hereby give permission to, and hereby authorize, the holder of this Insurance Disclosure, Waiver, and Permission Slip, as a representative and member of the Church, in the event of an emergency to act in my stead to consent to any medical treatment or hospitalization deemed necessary by a licensed physician or emergency team. I agree to be solely responsible for any and all costs involved in, or associated with, such medical or emergency treatment or hospitalization and hereby agree to hold the Church harmless from and against any and all such costs

In consideration of my participation in the Church’s programs and activities during the period in question, acting on my own behalf, I hereby release and discharge the Church, and/or any representatives of the Church involved in any and all activities during the aforementioned time period, from any and all liabilities whatsoever in exercising this permission.  In addition, I hereby agree to hold the Church harmless from and against any and all liabilities, claims, causes of action or damages stemming from exercise of the permission set forth in this document.

Functions and Activities

I understand that participating in programs, recreation and other activities of St. John’s Episcopal Church and Shepherd of the Mountains Church is a privilege.  Prior to my participation in such activities, I acknowledge that there are certain risks associated with these activities, including, by way of example, physical injury due to activity-related accidents, physical injury due to transportation-related accidents, illness or even death.  In addition, I acknowledge that there may be other risks inherent in these activities of which I may not be presently aware.

Today's Date: April 23, 2024

First Participant's Name

First Name*

Last Name*
First Participant's Date of Birth*
First Participant's Information

Personal Medical Information


Physician's Name:

Physician's Phone:

Physical limitations (asthma, diabetes, etc.) and/or special instructions (allergic to certain medications, foods, bees, etc., wears contact lenses, etc.)

List all medications taken on a regular basis and/or any in your possession (EpiPen, etc. All prescriptions MUST have a pharmacy label and name of doctor).

List all operations/serious injuries or diagnoses and dates within past 5 years:
First Participant's Signature*
Second Participant's Name

First Name*

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

Personal Medical Information


Physician's Name:

Physician's Phone:

Physical limitations (asthma, diabetes, etc.) and/or special instructions (allergic to certain medications, foods, bees, etc., wears contact lenses, etc.)

List all medications taken on a regular basis and/or any in your possession (EpiPen, etc. All prescriptions MUST have a pharmacy label and name of doctor).

List all operations/serious injuries or diagnoses and dates within past 5 years:
Third Participant's Name

First Name*

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

Personal Medical Information


Physician's Name:

Physician's Phone:

Physical limitations (asthma, diabetes, etc.) and/or special instructions (allergic to certain medications, foods, bees, etc., wears contact lenses, etc.)

List all medications taken on a regular basis and/or any in your possession (EpiPen, etc. All prescriptions MUST have a pharmacy label and name of doctor).

List all operations/serious injuries or diagnoses and dates within past 5 years:
Fourth Participant's Name

First Name*

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

Personal Medical Information


Physician's Name:

Physician's Phone:

Physical limitations (asthma, diabetes, etc.) and/or special instructions (allergic to certain medications, foods, bees, etc., wears contact lenses, etc.)

List all medications taken on a regular basis and/or any in your possession (EpiPen, etc. All prescriptions MUST have a pharmacy label and name of doctor).

List all operations/serious injuries or diagnoses and dates within past 5 years:
Fifth Participant's Name

First Name*

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

Personal Medical Information


Physician's Name:

Physician's Phone:

Physical limitations (asthma, diabetes, etc.) and/or special instructions (allergic to certain medications, foods, bees, etc., wears contact lenses, etc.)

List all medications taken on a regular basis and/or any in your possession (EpiPen, etc. All prescriptions MUST have a pharmacy label and name of doctor).

List all operations/serious injuries or diagnoses and dates within past 5 years:
Sixth Participant's Name

First Name*

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

Personal Medical Information


Physician's Name:

Physician's Phone:

Physical limitations (asthma, diabetes, etc.) and/or special instructions (allergic to certain medications, foods, bees, etc., wears contact lenses, etc.)

List all medications taken on a regular basis and/or any in your possession (EpiPen, etc. All prescriptions MUST have a pharmacy label and name of doctor).

List all operations/serious injuries or diagnoses and dates within past 5 years:
Seventh Participant's Name

First Name*

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

Personal Medical Information


Physician's Name:

Physician's Phone:

Physical limitations (asthma, diabetes, etc.) and/or special instructions (allergic to certain medications, foods, bees, etc., wears contact lenses, etc.)

List all medications taken on a regular basis and/or any in your possession (EpiPen, etc. All prescriptions MUST have a pharmacy label and name of doctor).

List all operations/serious injuries or diagnoses and dates within past 5 years:
Eighth Participant's Name

First Name*

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

Personal Medical Information


Physician's Name:

Physician's Phone:

Physical limitations (asthma, diabetes, etc.) and/or special instructions (allergic to certain medications, foods, bees, etc., wears contact lenses, etc.)

List all medications taken on a regular basis and/or any in your possession (EpiPen, etc. All prescriptions MUST have a pharmacy label and name of doctor).

List all operations/serious injuries or diagnoses and dates within past 5 years:
Ninth Participant's Name

First Name*

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

Personal Medical Information


Physician's Name:

Physician's Phone:

Physical limitations (asthma, diabetes, etc.) and/or special instructions (allergic to certain medications, foods, bees, etc., wears contact lenses, etc.)

List all medications taken on a regular basis and/or any in your possession (EpiPen, etc. All prescriptions MUST have a pharmacy label and name of doctor).

List all operations/serious injuries or diagnoses and dates within past 5 years:
Tenth Participant's Name

First Name*

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

Personal Medical Information


Physician's Name:

Physician's Phone:

Physical limitations (asthma, diabetes, etc.) and/or special instructions (allergic to certain medications, foods, bees, etc., wears contact lenses, etc.)

List all medications taken on a regular basis and/or any in your possession (EpiPen, etc. All prescriptions MUST have a pharmacy label and name of doctor).

List all operations/serious injuries or diagnoses and dates within past 5 years:
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

First Name*

Last Name*

Emergency Contact's Phone Number*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.


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*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Personal Medical Information


Physician's Name:

Physician's Phone:

Physical limitations (asthma, diabetes, etc.) and/or special instructions (allergic to certain medications, foods, bees, etc., wears contact lenses, etc.)

List all medications taken on a regular basis and/or any in your possession (EpiPen, etc. All prescriptions MUST have a pharmacy label and name of doctor).

List all operations/serious injuries or diagnoses and dates within past 5 years:
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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