Activities for All Abilities

Buddy Registration

This waiver form is for buddy registrants under the age of 18 to be signed by a parent/legal guardian.

Registration Form & Information

If you have any questions about the program please contact Dr. Mindy MacRone-Wojton, her email is in the above flyer.

Thank you so much for your willingness to volunteer with our program! We are very excited to begin!

Buddy Participant Name

First Name

Last Name

Participant Birth Date

MM

DD

YYYY

Allergy Alerts

Please list any allergies including medications.

Any other medical information or concerns that we need to know?

Parent/Guardian Name

First Name

Last Name

Cell Phone Number

(###)

###

####

Email

Guardian contact information

for any additional names/phone numbers different than above.

Photo Release

Crossroads Presbyterian Church and Gwynedd Mercy University would like to take pictures of the participants and the activities they are participating in. Do we have your permission to take your child's picture to use in the academic setting, church newsletter, social media and print platforms?

Yes

No

Parent/Guardian Signature for Photo Release, Liability Release, Medical Treatment Permission, Early Return Home Policy

Please sign by typing your full name in the box below. IT IS THE INTENTION OF GUARDIAN BY THIS AGREEMENT TO EXEMPT AND RELIEVE ORGANIZATION AND ITS OFFICERS, AGENTS, SERVANTS, OR EMPLOYEES FROM LIABILITY FOR PERSONAL INJURY, PROPERTY DAMAGE, OR WRONGFUL DEATH OF MINOR CAUSED BY ANY ACT OF NEGLIGENCE OF ORGANIZATION AND ITS OFFICERS, AGENTS, SERVANTS, OR EMPLOYEES. For and in consideration of permitting (MINOR) to observe, or use any facility or equipment of Crossroads Presbyterian Church for Adaptive Sports Disability Program participants and buddies, or engage in and/or receive instruction in any activity or activity incidental thereto SOME OF WHICH MAY INVOLVE DANGERS AND RISK OF BODILY INJURY at: (Crossroads Presbyterian Church in the Township of Limerick, County of Montgomery, and State of Pennsylvania, beginning on the day of January 21st 2025, the undersigned parent and/or guardian of (MINOR): hereby voluntarily and absolutely releases, discharges, waives, and relinquishes any and all loss or damages or actions or causes of action for personal injury, property damage, or wrongful death occurring to (MINOR) as a result of (MINOR)'s observing or using facilities or equipment of ORGANIZATION, or engaging in or receiving instructions in any activities SOME OF WHICH MAY INVOLVE DANGERS AND RISK OF BODILY INJURY or in activities incidental thereto wherever or however the same may occur, and for whatever period said activities or instructions may continue. The undersigned parent or guardian of MINOR for him/herself, his/her heirs, executors, administrators, or assigns agrees that in the event any claim for personal injury, property damage, or wrongful death shall be prosecuted against ORGANIZATION or its officers, agents, servants, or employees, the undersigned parent or guardian will indemnify and hold harmless ORGANIZATION and its officers, agents, servants, or employees from any and all claims or causes of action by (MINOR) or by any other person or entity, by whomever or wherever made or presented, and under no circumstances will the undersigned parent or guardian of MINOR present any claim against ORGANIZATION and said persons for personal injuries, property damage, wrongful death, or otherwise, caused by any act of negligence by ORGANIZATION and said persons. The undersigned parent or guardian represent that he/she has read this Release, has requested and has been provided with, or has requested and declined advisement on the potential dangers/risks of engaging in the observation, activities, or instruction offered, assumes all risks associated with such dangers and risks, and is fully aware of and understands the terms and the legal consequences of the signing of this Release. The undersigned parent or legal guardian intends his or her signature to be a complete and unconditional release of all liability to the greatest extent allowed by law and if any portion of the Release is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. Medical Treatment Permission: I authorize an adult, in whose care the minor has been entrusted, to consent to any emergency x-ray examination, anesthetic, medical, surgical, or dental diagnosis, or treatment hospital care, to be rendered to the minor under the general or special supervision and on the advice of any physician or dentist licensed under the provision of the Medical Practice Act on the medical staff of a licensed hospital or emergency care facility. The undersigned shall be liable and agrees to pay all costs and expenses incurred in connection with such medical and dental services rendered to the aforementioned child or youth pursuant to this authorization. Early Return Home Policy Should it be necessary for my child or youth to return home due to medical reasons disciplinary action or otherwise, the undersigned shall assume all transportation costs and responsibility.

Checkbox

I agree to the Liability Release, Medical Treatment Permission, Early Return Home Policy.

Today's Date

MM

DD

YYYY

Activities for All Abilities

Buddy Registration

This waiver form is for buddy registrants under the age of 18 to be signed by a parent/legal guardian.

Registration Form & Information

*****************Thank you for your submission! Your form has been recorded and emailed to Dr. Wojton.