Adult Waiver & Medical Release

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Medical Information Please complete every block on this page. If the area does not apply, mark n/a
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Hanover Community Church Adult Activity Waiver and Release from Liability
My signature indicates my consent to the following: I hereby consent to participate in the activity or activities of Hanover Community Church (“HCC” or the “Church”) from August 2018 through August 2019 (hereafter the “Activity”) including any transportation or travel that may be necessary to and from the Activity venue, including if the Activity is outside the Commonwealth of Pennsylvania. I represent that I am in good health and physically able to participate in the Activity. I further represent that the information supplied on this Release is accurate, including the medical and medication information submitted.

I recognize that there are risks involved in participating in this Activity and hereby assume all risk of injury, harm, damage, or death in connection with my participation in this Activity. It is understood that every reasonable precaution will be taken for my safety and well-being and to the fullest extent permitted by law, I release HCC, its trustees, officers, directors, employees, agents and representatives from any injury, harm, damage or death which may occur while participating in the Activity and agree to release and hold harmless HCC, its trustees, officers, directors, employees, agents and representatives from and against any and all claims, liabilities, suits, actions, administrative proceedings, costs, fines, losses, penalties and damages, whether brought by myself, a person acting on my behalf or my estate, including, without limitation, reasonable attorneys’ fees, arising out of, or resulting from my participation in the Activity. I agree to indemnify HCC for any liability due to my participation in the Activity.

In case of a medical emergency involving myself, I hereby grant HCC a limited medical power of attorney as follows:

I give permission to the physician selected by a HCC representative to hospitalize and secure proper treatment for me. I have provided HCC with a medical information form including emergency contact information. I consent to any x-ray examination, anesthetic, medical, or surgical diagnosis or treatment and hospital care under the general or special supervision and upon the advice of or to be rendered by a physician or surgeon. This authority also extends to any x-ray examination, anesthetic, dental, or surgical diagnosis or treatment and hospital care by a dentist. I further agree to pay all charges for the dental, medical, or hospital care or treatment and to reimburse HCC for any charges it incurs for my care. I represent that my consent to and agreement to pay for the dental, medical, or hospital care or treatment to be rendered is legally sufficient and that no consent from any other person is required by law.

This form may be signed by hand or by digital or electronic means. In accordance with the Pennsylvania Electronic Transactions Act and the Electronic Signatures in Global and National Commerce Act, I agree that any digital or electronic signature that I apply to this form shall have the same binding effect as my handwritten signature to the fullest extent permitted under the law.

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