Medical Release Form

Instructions

Please fill out all fields and sign at the bottom. Use your mouse to draw your signature, or if you have a touch screen, use your finger. The form will not allow you to submit without information in all fields. If there is a field that does not apply to you, please write N/A. Once you hit submit, a copy of this form will be sent to CIY and emailed to the Leader in charge of your group, as well as to you. If you have trouble with this form or questions, please contact CIY at 417-781-2273. Javascript must be enabled to fill out the form. Error Code: 2290.

The Participant Is:* Participant First Name* Participant Last Name* Gender* Age*

Note: Please use 2 digits. ex: 09

Date of Birth*

Grade**Year in school

Address* Address 2 City* State* Zipcode* Participant Email* Home Phone*

Graduation Year*

Church You Are Attending With* City* State* Group Leader's First Name* Group Leader's Last Name* Health Insurance Company Policy Number Known Allergies and Reactions Medications Currently Taking

Parent/Legal Guardian Contact Info:

Parent/Legal Guardian First Name*With Whom You Live* Parent/Legal Guardian Last Name* Cell Phone* Parent/Legal Guardian Email*

Emergency Contact
(Other than Parent listed above)

First Name* Last Name* Relationship* Phone*

I, the participant (the individual identified on this form) understand that all participants are required to abide by the Program rules and be directly responsible to the Christ In Youth Program Director. The Christ In Youth Program Director assumes responsibility for discipline at the Program and, if necessary, may, because of misconduct or disobedience, require a participant to leave. In such instance, I will assume full responsibility for the cost of returning home.

I acknowledge it is my responsibility to ensure that I engage in all safety measures suggested or required by the Centers for Disease Control (CDC) and applicable local ordinances or state law concerning COVID-19. In addition, if at any time I believe that conditions are unsafe or I am unable to participate due to physical or medical conditions, then I will immediately discontinue participation. I understand that despite diligent hygiene measures and compliance with the law, there is no guarantee that infectious transmission will not occur.

I understand symptoms of COVID-19 include:

Fever
Fatigue
Dry Cough
Difficulty Breathing

Screenings will be conducted upon arrival and on each day of the event. I understand that the following must be true statements at the start of the event and will not attend if any of the following are not true when the event begins:

I understand the above symptoms and affirm that I, as well as all household members, do not currently have, nor have experienced the symptoms listed above within the last 14 days.
I affirm that I, as well as all household members, have not been diagnosed with COVID-19 within the past 30 days.
I affirm that I, as well as all household members, have not knowingly been exposed to anyone diagnosed with COVID-19 within the past 30 days.
I affirm that I, as well as all household members, have not traveled outside of the country or to any city considered to be a “hot spot” for COVID-19 infections within the past 30-days.
I understand that Christ In Youth cannot be held liable for any exposure to the COVID-19 virus caused by misinformation on this form or the health history provided by each participant in Christ In Youth events.
I acknowledge the contagious nature of the Coronavirus/COVID-19 and that the CDC and many other public health authorities still recommend practicing social distancing.
I further acknowledge that Christ In Youth cannot guarantee that I will not become infected with COVID-19. I understand that the risk of becoming exposed to and/or infected by the COVID-19 may result from the actions, omissions, or negligence of myself and others, including, but not limited to, Covered Parties and other participants engaged in Christ In Youth activities and their families.

Further, I hereby release and forever discharge a) Christ In Youth and its directors, officers, employees, Program Directors, agents and all other persons or entities acting on their behalf (the “Covered Parties”) and b) the lessor/owner of properties on which the Programs are held, from any and all liability, claims, or demands for personal injury, sickness or death, as well as property damages and expenses, of any nature whatsoever which may be incurred by the participant, the undersigned, and/or any member of the participant’s family by reason of participating in any activities associated with Christ In Youth Programs WHETHER OR NOT SUCH CLAIMS, ACTIONS, DEMANDS, LIABILITY, COSTS OR EXPENSES ARE CAUSED BY THE NEGLIGENCE OR OMISSION OF ANY OF THE COVERED PARTIES.

Further, I hereby agree to indemnity and hold harmless a) Christ In Youth and its directors, officers, employees, Program Directors, agents and all other persons or entities acting on their behalf (the “Covered Parties”) and b) the lessor/owner of properties on which the Programs are held, from any and all liability, claims, or demands for personal injury, sickness or death, as well as property damages and expenses, of any nature whatsoever which may be incurred by the participant, the undersigned, and/or any member of the participant’s family by reason of participating in any activities associated with Christ In Youth Programs WHETHER OR NOT SUCH CLAIMS, ACTIONS, DEMANDS, LIABILITY, COSTS OR EXPENSES ARE CAUSED BY THE NEGLIGENCE OR OMISSION OF ANY OF THE COVERED PARTIES.

Further, I do authorize the minister or sponsor of the Program, or any Christ In Youth staff member to take me to a doctor or hospital and I hereby authorize medical treatment, including but not limited to emergency surgery or medical treatment, and I hereby assume financial responsibility for all expenses incurred for such treatment and, if necessary, all expenses to return home.

Further, I hereby assume all risk of personal injury, sickness, death, damage and expense as a result of the participation in this Christ In Youth Program. I hereby release and agree to hold harmless and indemnify the Covered Parties, for any liability and/or expense sustained as the result of my negligent, willful or intentional acts, including damages to the Program facility and/or keys not returned at the time of group checkout. I agree to pay for keys not returned at time of group checkout or damage done to any Program facility or Christ In Youth property by me.

For valuable consideration received, I hereby irrevocably grant to Christ In Youth, Inc. the worldwide, royalty-free, right to use my name, voice, likeness, and image in all forms and media, and in all manners for any lawful purposes, commercial or noncommercial. I understand that my participation makes me eligible to receive educational information and updates regarding ministry successes and opportunities.

If any portion of this agreement is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. I further agree this agreement will be governed by and construed in accordance with the laws of the State of Missouri without giving effect to the principles of conflict of law and the courts within Missouri will be the only courts of competent jurisdiction. I hereby irrevocably submit to the personal jurisdiction of the courts of Jasper County, Missouri.

I hereby certify that I have carefully read the foregoing and acknowledge that I understand and agree to all of the above terms and conditions.

I, the participant or for those under 18 the parent or legal guardian of the participant listed on this form, certify that he/she has my full approval to participate in this Christ In Youth Program. The individual identified on this form understands that all participants are required to abide by the Program rules and be directly responsible to the Christ In Youth Program Director. The Christ In Youth Program Director assumes responsibility for discipline at the Program and, if necessary, may, because of misconduct or disobedience, require a participant to leave. In such instance, I will assume full responsibility for returning the participant home.

I acknowledge it is my responsibility to ensure that myself and the minor listed above engage in all safety measures suggested or required by the Centers for Disease Control (CDC) and applicable local ordinances or state law concerning COVID-19. In addition, if at any time I believe that conditions are unsafe or that the minor listed above is unable to participate due to physical or medical conditions, then I will immediately discontinue their participation. I understand that despite diligent hygiene measures and compliance with the law, there is no guarantee that infectious transmission will not occur.

I understand symptoms of COVID-19 include:

Fever
Fatigue
Dry Cough
Difficulty Breathing

Screenings will be conducted upon arrival and on each day of the event. I understand that the following must be true statements concerning the minor listed above at the start of the event and will not permit the minor listed above to attend if any of the following are not true when the event begins:

I understand the above symptoms and affirm that the minor listed above, as well as all household members, do not currently have, nor have experienced the symptoms listed above within the last 14 days.
I affirm that the minor listed above, as well as all household members, have not been diagnosed with COVID-19 within the past 30 days.
I affirm that the minor listed above, as well as all household members, have not knowingly been exposed to anyone diagnosed with COVID-19 within the past 30 days.
I affirm that the minor listed above, as well as all household members, have not traveled outside of the country or to any city considered to be a “hot spot” for COVID-19 infections within the past 30-days.
I understand that Christ In Youth cannot be held liable for any exposure to the COVID-19 virus caused by misinformation on this form or the health history provided by each participant in Christ In Youth events.
I acknowledge the contagious nature of the Coronavirus/COVID-19 and that the CDC and many other public health authorities still recommend practicing social distancing.
I further acknowledge that Christ In Youth cannot guarantee that the minor listed above will not become infected with COVID-19. I understand that the risk of becoming exposed to and/or infected by the COVID-19 may result from the actions, omissions, or negligence of myself, the minor listed above and others, including, but not limited to, Covered Parties and other participants engaged in Christ In Youth activities and their families.

Further, I do authorize the minister or sponsor of the Program, or any Christ In Youth staff member to take the participant to a doctor or hospital and I hereby authorize medical treatment, including but not limited to emergency surgery or medical treatment, and I hereby assume financial responsibility for all expenses incurred for such treatment and, if necessary, all expenses to return the participant home.

Further, I hereby assume all risk of personal injury, sickness, death, damage and expense as a result of the participation in this Christ In Youth Program. I hereby release and agree to hold harmless and indemnify the Covered Parties, for any liability and/or expense sustained as the result of negligent, willful or intentional acts of the participant, including damages to the Program facility and/or keys not returned at the time of group checkout. I agree to pay for keys not returned at time of group checkout or damage done to any Program facility or Christ In Youth property by the participant.

For valuable consideration received, I hereby irrevocably grant to Christ In Youth, Inc. the worldwide, royalty-free, right to use the participant’s name, voice, likeness, and image in all forms and media, and in all manners for any lawful purposes, commercial or noncommercial. I understand that my participation makes me eligible to receive educational information and updates regarding ministry successes and opportunities.

I do not wish to receive information about educational opportunities. Do not send me communication unrelated to the event.

I acknowledge this agreement is intended to be as broad and inclusive as permitted by the laws of the state of Missouri and that if any portion hereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. I further agree this agreement will be governed by and construed in accordance with the laws of the State of Missouri without giving effect to the principles of conflict of law and the courts within Missouri will be the only courts of competent jurisdiction. I hereby irrevocably submit to the personal jurisdiction of the courts of Jasper County, Missouri.

I hereby certify that I have carefully read the foregoing and acknowledge that I understand and agree to all of the above terms and conditions

Printed Name of Participant*

Signature of Participant*

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Printed Name of Parent/Legal Guardian*

Signature of Parent/Legal Guardian*

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I understand and acknowledge that this form is being submitted electronically. Further, I attest that the signature affixed here is that of the person named as the parent or legal guardian of the participant named herein (for those under 18) or of the participant named herein (for those 18 and over). My signature on this form transmitted in electronic format shall be treated as an original signature in all purposes. I understand that this electronic form is legally binding as if submitted as a physically signed original.

I agree to all legal terms.

**This form is required by the University of Nebraska - Lincoln even though MOVE is not an athletic camp. Attendees have access to some of their recreational facilities which requires a signed waiver.

Wheaton College, Wheaton Il, Waiver and Release of Liability

In consideration of my participation, or my child’s participation, in sports and recreational activities at Wheaton College (the “College”),
I hereby forever release and covenant not-to-sue Wheaton College, the Wheaton College Board of Trustees, and any of their employees, instructors, volunteers, agents, and all others who are involved, from any and all present and future claims, demands, losses, liabilities, obligations, damages, causes of action, and costs (including attorney’s fees), resulting from ordinary negligence on the part of Wheaton College, or others listed, for property damage, personal injury, or wrongful death, arising from participation in sports and recreational activities on College property, use of College facilities, equipment and fields, or any activities incidental thereto, including receiving instruction, local travel, and other activities not listed, wherever, whenever, or however the same may occur.

I hereby voluntarily waive any and all claims both present and future, resulting from ordinary negligence, that may be made by me, my family, estate, heirs, or assigns, and I relinquish on behalf of myself, spouse, heirs, estate and assigns the right to recover for injury or death.

I represent and warrant that I as a participant am, or my child as a participant is, in good health and in good physical condition, and able to participate in the sports and recreational activities that I, or my child, have chosen. I agree that I will not undertake, and will not permit my child to undertake, any activity that is not within I or my child’s physical capabilities.

I am aware that sports and recreational activities may be vigorous and can involve severe cardiovascular stress and violent physical contact, and that participation in these activities, and the use of College facilities, equipment and fields may involve certain risks. Full disclosure has been made to me of the risks and dangers connected with these activities. I understand that participation can result in death; coma, paralysis, drowning, stopped breathing, heart attack, stroke, cancer, and infectious disease; head injury, concussion, traumatic brain injury, neck or spinal cord injury, nerve damage, blood clots, complete or partial paralysis, including the loss or impairment of movement, strength, feeling, or use or function of body parts; injury to joints, ligaments, tendons, muscles, internal organs, eyes and skin, including but not limited to cuts, puncture wounds, burns, bruises, sprains, and broken bones; injury that may result in trauma, illness, disease, disfigurement, loss of mobility, speech impairment, vision impairment, blindness, and hearing loss; injury related to falls or collisions with persons or objects; injury that may cause choking, difficulty breathing, hyperventilation, seizure and unconsciousness; injury related to temperature or weather conditions, including dehydration, heat exhaustion, sunburn, heat stroke, frostbite, hypothermia, lightning strike, hail, and strong winds; injury from the use or non-use of sports equipment; injury related to travel; injury due to the inaccessibility of emergency medical care or negligent medical care in the treatment of an injury; injury due to the negligent acts or omissions of College personnel; injury due to the possible reckless conduct of other participants; injury due to the negligent or intentional acts or omissions of others; property loss caused by theft, vandalism, or damage, including property owned by me or property owned by others for which I am responsible, and other injury or loss not listed regardless of cause. I am voluntarily participating, or allowing my child to participate, in these sports and recreational activities with knowledge of the danger involved, and hereby agree to accept any and all risks of property damage, personal injury, or death.

I understand that such injuries may result in a significant impairment of my or my child’s future abilities to earn a living, to engage in social and recreational activities, to produce a family, and to enjoy life. I further acknowledge that such injuries can be serious or severe and could last my entire life, or the entire life of my child.

I am aware of the risks, dangers, and hazards associated with participation in sports and recreational activities, and the activities incidental thereto, including those listed above as well as those not specified or anticipated. I personally and completely accept these risks for myself, and for my child, including those which may result in my, or my child’s, death, injury, illness, and damage to my or my child’s property, or the property for which I am, or my child is, responsible. I will not hold the College or those listed liable for any injury or damage associated with my or my child’s participation in these activities.

I understand and agree that I am responsible for my and my child’s personal safety, and the safety of others, to the extent that my or my child’s actions or inactions may contribute to an injury or loss. I acknowledge that safety overrides all other concerns. Should I become aware of a danger or risk I agree to take appropriate actions, and to communicate these actions to the College.

I further agree to indemnify and hold harmless Wheaton College and others listed above for any and all claims arising as a result of my or my child’s participation in sports and recreational activities on College property, use of College facilities, equipment and fields, or any activities incidental thereto, including receiving instruction, local travel, and other activities not listed, wherever, whenever, or however the same may occur.

I understand and agree that this waiver is intended to be as broad and inclusive as permitted by Illinois law, and shall be interpreted, enforced under, and governed by the laws of Illinois. I agree that if any portion is held invalid, the remainder of the waiver will continue in full legal force and effect. I further agree that the venue for any legal proceedings shall be in the state of Illinois.

I represent and warrant that I have carefully read and understand this agreement, and have been given the opportunity to discuss with Wheaton College the risks and dangers connected with my or my child’s participation in sports and recreational activities on College property, and have entered into this agreement knowingly, voluntarily, and of my own free will; and intend to abide by its provisions without exception.

I affirm that I am of legal age and am freely signing this agreement, and that if signing for my child I am the child’s legal guardian. I have read this form and fully understand and agree that, by signing this form, I am giving up legal rights and/or remedies which may be available to me for the ordinary negligence of Wheaton College or any of the parties listed above.

Signature of Parent/Legal Guardian*

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Requirements, Disclosures and Attestation by the Participant

As an Adult Leader at a Christ In Youth event you (the Participant) are required to read and acknowledge or respond to the items that follow. Failure to complete these items or uphold the requirements communicated in this document will result in exclusion or removal from attending or serving at the Christ In Youth event listed above – or any other until all items are satisfactorily completed.

Mandated Reporting

As an Adult Leader at a Christ In Youth event you are considered a Mandated Reporter. Specifics about making mandated reports vary by state, however generally require adults working closely with a vulnerable population (in this case minors) to report to appropriate authorities (as designated by the state where abuse is suspected) known or suspected instances of child abuse or neglect. As an adult leader at a Christ In Youth event it is your responsibility to and you hereby agree that you have or will (prior to arriving at the event listed above) apprise yourself of the mandated reporting requirements in your state of residence as well as the state of the event you are attending. Further, by initialing below you affirm your understanding of the responsibility you have accepted to serve as a mandated reporter by virtue of your involvement with this or any Christ In Youth event. Generalized information and links to more specific resources are provided here: https://www.childwelfare.gov/pubPDFs/manda.pdf.

(Initial) I understand, agree to and will fulfill my obligations as a Mandated Reporter

Background Check

As an Adult Leader at any Christ In Youth event you will be required to submit to a background check and may be disallowed to participate as an Adult Leader if the results of that check – at the sole discretion of Christ In Youth – are inconsistent with participation in the event and/or working with minors. The specific check(s) that will be completed may vary depending on local requirements, but will include at a minimum a National Criminal & Sex Offender check. By initialing below, I agree to complete any required waiver (as requested by Christ In Youth or the church I am attending the event with) in order for the check(s) to be run as well as bear any costs associated with the check(s) (unless my church covers the cost). Further I agree not to sue or otherwise bring any action in law or in equity against Christ In Youth, the host facility, or the church I am scheduled to attend the event with as a result of any action taken by the named parties as a result of any information revealed in the background check(s) completed on me.

(Initial) I understand that I must successfully complete the required background check(s) at my (or my church’s) expense prior (at the direction of either Christ In Youth or the church I am attending the event with) to attending this or any Christ In Youth event and agree not to pursue any action against any party named above related to actions taken as a result of information revealed through the completion of the background check(s).

Required Training

In order to participate in a Christ In Youth event as an adult leader you are required to successfully complete an approved (at Christ In Youth’s discretion) child abuse awareness training prior to arriving at the event. Failure to successfully complete the training will result in your exclusion from participating in or being present at this or any Christ In Youth event. You or your church will be responsible for any cost associated with the required training.

(Initial) I understand that I must and agree to complete the required child abuse awareness training prior to attending this or any Christ In Youth event.

Attestation

By initialing each item below I attest as follows:

(Initial) I agree to abide by the rules, guidelines and procedures of Christ In Youth and the host facility/campus as well as adhering to all local, state, and federal laws and statutes while serving as an Adult Leader at this or any Christ In Youth Event.

(Initial) I have never been convicted of a felony or accused of or arrested for child abuse or a crime involving actual or attempted molestation, abuse or neglect of a minor. (failure to initial this item will preclude your participation as an adult leader at Christ In Youth events pending review of the details provided below)

***If you did not initial the item above, explain why not:

(Initial) To the best of my knowledge, under penalty of perjury, all information provided in this form is true, accurate and complete.

I have read, understood and agree to everything in this document and understand that my failure to complete or abide by any of the requirements listed herein or communicated to me by Christ In Youth will /result in my exclusion or removal from serving as an Adult Leader at this or any Christ In Youth event.

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Date

Instructions

Parent/Legal Guardian Contact Info:

Emergency Contact (Other than Parent listed above)

Wheaton College, Wheaton Il, Waiver and Release of Liability

Requirements, Disclosures and Attestation by the Participant

Mandated Reporting

Background Check

Required Training

Attestation

Emergency Contact
(Other than Parent listed above)