2025-2026 SRPC Release, Waiver & Medical Consent Form

Your name *

Last name

Email address *

Release and Waiver of Liability & Registration and Medical Consent Form

This Release and Waiver of Liability (the “Release”) is in favor of SAN RAMON PRESBYTERIAN CHURCH, a non-profit corporation organized and existing under the laws of the State of California, USA, its directors, officers, employees, volunteers and agents (collectively, and from here on referred to as, “SRPC”).

I, the participant, desire to, or desire my child to, participate with SRPC in all activities during the 2025 – 2026 year starting June 2025 and extending to June 2026. I, or my child, has permission to engage in all the activities related to being a participant in youth group. I understand that the activities may include but are not limited to, walking, being transported to and from site locations, overnight stays at camp or retreats, consuming food, being in the sun, riding roller coasters, ropes course, laser tag, beach days, service projects, waterslides, sports events, all-nighters and other participatory related activities.

I, the participant, and or guardian of participant, hereby freely and voluntarily, without duress, execute this Release under the following terms:

Waiver and Release. I, the Participant, release and forever discharge and hold harmless SRPC from any claim or liability that I, the Participant, may have against SRPC with respect to any bodily injury, personal injury, illness, death or property damage that may result from my participation in all such activities. I also understand that SRPC does not assume any responsibility for or obligation to provide financial assistance or other assistance, including, but not limited to medical, health or disability insurance, in the event of injury, illness, death or property damage (see insurance requirements below).

Insurance. I, the Participant, understand that SRPC does not carry or maintain, and expressly disclaims responsibility for providing any health, medical or disability insurance coverage for the Participant.

Medical Treatment. Except as otherwise agreed to by SRPC in writing, I, the participant, hereby release and forever discharge SRPC from any claim whatsoever which arises or may hereafter arise as a result of any first-aid treatment or other medical services rendered in connection with an emergency during my time with SRPC.

Assumption of Risk. I understand that my time with SRPC may include activities that may be hazardous to me, including, but not limited to, walking, riding roller coasters, ropes course, laser tag, singing, dancing, swimming, running, lifting heavy objects, and local transportation to and from all locations. So, I recognize and hereby expressly and specifically assume the risk of injury or harm in these activities and release SRPC from all liability for injury, illness, and death or property damage resulting from the activities of my time with SRPC.

Photographic Release. I grant and convey unto SRPC all right, title and interest in any and all photographic images and video or audio recordings made by SRPC during my participation with SRPC, including, but not limited to, any royalties, proceeds or other benefits derived from such photographs or recordings.

Other. I expressly agree that this Release is intended to be as broad and inclusive as permitted by the laws of the State of California in the United States of America, and this Release shall be governed by and interpreted in accordance with the laws of the State of a California. I agree that in the event that any clause or provision of this Release shall be held to be invalid by any court of competent jurisdiction, the invalidity of such clause or provision shall not otherwise affect the remaining provisions of this Release which shall continue to be enforceable.

Medical Consent:

In case of emergency, I understand that SRPC, through the person in charge, will first attempt to notify me or the alternate contact listed. In the event we cannot be reached, I hereby authorize to the physician or hospital selected by SRPC, or the person in charge to, hospitalize, secure proper treatment, and/or order an injection, anesthesia or surgery for my child as deemed necessary. I understand that the undersigned will assume full financial responsibility for all expenses incurred for any of the foregoing services and release SRPC of any liability.

Please complete the following information for each student who will be involved in SRPC Student Ministries’ activities. This form will become a part of SRPC’s permanent files for all insurance purposes and in compliance with California State Law.

I, the undersigned have read and fully understand the contents of this document and agree to abide by it:

I agree that my electronic signature is the legal equivalent of my manual/handwritten signature on this document. By selecting “I agree” using any device, means, or action, I consent to the legally binding terms and conditions of this document. *

Signee Information:

First Name *

Last Name *

Birthdate *

Phone Number *

Email Address *

Address *

Address Line 2

City *

State *

Zip Code *

Emergency Contact Info

Primary Contact Name *

Relationship to participant(s) *

Phone Number *

Secondary Contact Name *

Relationship to participant(s) *

Phone Number *

Alternate Contact Name *

Relationship to participant(s) *

Phone Number *

Enter participant's Full Name

First Name *

Last Name *

Birthdate (MM/DD/YYYY) *

Preferred Name

Grade (for next school year) *

6th

7th

8th

9th

10th

11th

12th

Other

School *

Gender *

Student Cell Phone

Student's Email

Medical Information

Allergies *

Medications *

Date of Tetanus Shot *

Best estimate is fine as long as it was within the last 10 years.

Physician's Name *

Physician's Phone *

Medical Insurance *

Insurance Policy # *

Add Another Participant?

Yes

I Agree *

By clicking 'I Agree' above, you agree that you have read and agree with the terms of the waiver and that the information you provided is accurate. You furthermore agree that your submission of this form, via the 'I Agree' button, shall constitute the execution of this document in exactly the same manner as if you had signed, by hand, a paper version of this agreement.

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San Ramon Presbyterian Church
office@srpc.org
(925) 543-7772