Activity Permission/Medical Release Form

Participant's Name:

Date of Birth:

Activity:

Date of Activity:

Legal Guardian if under 18 years of age:

Address:

City:

State:

ZIP:

Primary Contact Number:

Other numbers/work/cell/pager:

Emergency Contact (other than parent):

Relationship:

Phone number:

Medical Insurance:

Policy #:

Primary Physician (Name and phone number):

Participant Social Security # (hospitals require this number):

List any medication, allergies, or medical conditions that we need to be aware of:

Date of last Tetanus Toxiod Booster:

Authorization for Medical Treatment and Release

If my child, or I as an adult participant, become(s) injured or ill during an activity at The Gathering at Windsor or any activity which includes traveling with a 'Gathering' group, to and from an activity, I hereby authorize The Gathering at Windsor and/or a representative of The Gathering at Windsor to secure, at my expense, medical treatment including surgery, for my child or myself if I should be unconscious. I hereby authorize all health care providers to release all medical information regarding my child or me, if I am an adult participant, to my personal or group insurance company and to The Gathering at Windsor.

Furthermore, I understand that there is always risk with any activity and I will accept personal financial responsibility for any injury sustained during the activity. Further, I promise to indemnify, defend, and hold harmless the activity sponsor or its agents, employees, volunteers, or any other representatives (collectively referred to as the "Sponsor") for any injury related directly or indirectly to the described activity.

I give permission for my child/myself to participate in the above listed activity.

Date:

Parent/Legal Guardian/Adult Participant:

(Print Name)

Parent/Legal Guardian/Adult Participant:

(Signature)