Notice: The event in which you are voluntarily participating may include strenuous or potentially dangerous activities. The risk of injury from the activities involved in the program is significant, including the potential for paralysis and death. The rules, instructions, equipment, and personal discipline may reduce the risk of serious injury, but the potential for injury/death does still exist.
Representations: I verify that I am in good health and capable of participating in all activities in which I choose to participate. If necessary, I will tailor my participation to meet my personal physical or health limitations. I assume full responsibility for my participation in all activities and agree to abide by all rules, instructions, and warnings associated with each activity. If I observe any unusual hazard during my participation or feel my safety is at risk, I will remove myself from participation and notify the proper personnel.
Authorization for Treatment: I give permission to medical personnel selected by event personnel to secure and administer medical treatment to me. I recognize that any medical treatment provided will be paid for by my insurance company and I personally guarantee payment for medical services not paid insurance. Insurance provided by Life Impact, Inc. d/b/a Life Impact Ministries, if any, that may provide coverage for medical treatment will be secondary to my own insurance. I authorize Life Impact, Inc. d/b/a Life Impact Ministries to maintain and/or release any medical records as necessary as outlined under HIPAA regulations.
Indemnity: I release, and will not hold or attempt to hold liable, Life Impact, Inc. d/b/a Life Impact Ministries from any loss, liability, damage, expense, or claims for injury to my person (including death) or my property caused or alleged to be caused by any act or omission of any person, other than the willful or solely negligent acts of Life Impact, Inc. d/b/a Life Impact Ministries, its agents, or its employees. I will indemnify and hold harmless Life Impact, Inc. d/b/a Life Impact Ministries, including its agents, employees, officers, and directors, from and against all losses, liabilities, damages, expenses and claims (including reasonable expenses of litigation and attorneys’ fees) arising out of any act or omission of any person, other than the willful or solely negligent acts of Life Impact, Inc. d/b/a Life Impact Ministries, its agents, or its employees.
Media Release: I understand that Life Impact, Inc. d/b/a Life Impact Ministries may capture photographs, videos, sound recordings, or other media of me during this event. I grant Life Impact, Inc. d/b/a Life Impact Ministries permission to use, reproduce, and/or distribute all photographs, videos, sound recordings, or other media of me for the purpose of promoting the activities of Life Impact Ministries.
