Belgrade Church of Christ - Valley Rally - Youth Registration

Belgrade Church of Christ
909 Nevada, Belgrade, MT 59714

Liability Waiver and Permission Form

(Required for participation of minors)

Participant

First Name: Last Name: DOB: Gender: MaleFemale
Address: City: State: Zip:
Shirt Size: S M L XL XXL

Parent(s) or Legal Guardian(s)

First Name: Last Name: Phone: Text:
Email:

First Name: Last Name: Phone: Text:
Email:

Housing

Need Housing: YESNO

If you do not need housing, briefly explain your housing plans.

Housing Notes:

Permission

The undersigned does herby give permission for their child, ________ to attend and participate in the Valley Rally on the dates of January 17-19, 2025.

We (I) authorize an adult, in whose care the minor has been entrusted, to consent to any X-ray examination, anesthetic, medical, surgical or dental diagnosis or treatment, and hospital care, to be rendered to the minor under the general or special supervision and on the advice of any physician or dentist licensed under the provisions of the Medical Practice Act on the medical staff of a licensed hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital. The undersigned shall be liable and agrees to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child pursuant to this authorization.

Release of Liability

I hereby acknowledge that my child has voluntarily agreed to participate in the Valley Rally which involves hiking and other outdoor adventure related activities such as repelling. I understand that the above activities and all other hazards and exposures connected with these activities conducted in the outdoors do involve risk and I am aware of the risks and dangers inherent with these activities. I understand and agree that any bodily injury, death, or loss of personal property and expenses thereof as a result of my child’s negligence in any scheduled or unscheduled activities associated with this event are my (the undersigned) responsibilities. I agree to defend and hold harmless the participants and leaders of the Valley Rally for any injury or death caused by or resulting from my child’s participation in the activities, scheduled or unscheduled, whether or not such injury or death was caused by their negligence or from any other cause.

By signing my initials below, I certify this is a release of liability.

Participant Initials:
Parent or Legal Gardian Initial:

Insurance

Health Insurance Company:
Policy Number:
Emergency Phone: Text:
Emergency Phone: Text:

Allergies / Special Medical Considerations

Emergency Contact Information / Other Notes

Notes:

Signatures

Participant Signature:
Date:
Parent or Legal Guardian Signature:
Date: