Cornerstone Chapel

Participant Release of Liability and Assumption of Risk Agreement (Adult High Risk)

Participant Name:  
Event Name:
Event Start Date:
Event End Date:

In consideration of participating in this program’s related events and activities, I, the undersigned, acknowledge and agree that:

  1. As participation in such events and activities are a privilege, I understand and agree that I am expected to behave in a manner that best represents Cornerstone Chapel (the “Church”). As such, certain items and/or activities will not be tolerated and if caught in violation of these rules, I agree that I will be sent home at my own expense and will not be given a refund. These items/activities include but are not limited to 1) possession or use of alcohol, illegal or illicit drugs, or tobacco products of any kind; 2) any immoral sexual behavior; 3) verbal or physical abuse; and 4) any other rules established by the Church or any other sponsor involved. I am aware of the high risks associated with participation in such events, including but not limited to transportation to and from the activity, that I am participating in and do hereby voluntarily assume full responsibility for any risk of loss, property damage, or personal injury, including death, that may result from participation in the event activities. I am particularly aware that the activities involve me as an adult working at heights of at least four (4) feet above the ground and may involve use of tools and equipment that contain, pneumatic power, combustible engines, and/or bladed edges, and I have received proper training on how to use such tools and equipment in a safe and proper manner.
  2. I willingly agree to the terms and conditions for participation, on- or off-premises, and will remove myself from participation if I observe any unusual, significant hazard.
  3. I know my personal health and physical limitations and will remove myself from an activity if I feel participation would be detrimental to my emotional or physical health; and will accept responsibility for participating without regard to my known or unknown limitations.
  4. By participating in or attending any activity in connection with this program, I consent to the use of any and all photographic images and video or audio recordings taken of me or provided by me for promotional, website, or other related marketing materials or use, and waive any right of privacy, compensation, copyright, or other ownership right connected to the same.
  5. I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, do release, acquit, discharge, and covenant to hold harmless and indemnify Cornerstone Chapel, its representatives, their volunteers, activity leaders and assigns from any and all injuries, disabilities, actions, damages to persons or properties, and liabilities arising out of any incident, accident or sickness, or treatment thereof, incurred by my participation in this program and/or activities, to the fullest extent permitted by law.
  6. I am confident that the adult leaders and sponsors will take appropriate care of me and every effort will be made for my safety. However, I understand that accidents do occur, and in the event of an emergency, every effort will be made to contact the below-listed individual. In the event Cornerstone Chapel is unable to reach the below person immediately, I do hereby authorize an adult leader of this activity, as agent for me, to consent to any x-ray examination; medical, dental, or surgical diagnosis; treatment, and hospital care advised and supervised by a physician, surgeon, or dentist (as appropriate) licensed to practice under the laws of the state where the services are rendered, either at a doctor’s office or in any hospital. I agree that I have insurance coverage, and I will further agree to pay all fees and costs which arise from this action to obtain medical treatment. If I do not have medical insurance or if I am unable to obtain medical insurance, I agree to nevertheless pay all fees and costs which arise from this action to obtain medical treatment and expressly indemnify and do release, acquit, discharge and agree to hold harmless and indemnify Cornerstone Chapel, its representatives, volunteers, activity leaders, and assigns from any and all actions, damages, and liabilities arising out of the diagnosis and treatment of any accident or injury incurred by my participation in the above Event.
  7. I understand and acknowledge that, under the Uniform Electronic Transactions Act, by proceeding to register online and by signing this waiver electronically, such electronic registration and electronically signed Waiver will be valid and enforceable in the same manner as a hand-signed document that exists in physical form and that a record or signature may not be denied legal effect or enforceability under law solely because it is in electronic form. 8) In the event of any dispute or disagreement between parties listed with respect to this agreement, each party shall appoint a representative whose task it will be to meet with the representative appointed by the other party for the purpose to resolve any dispute. No legal action regarding the dispute may take place until either one of the two representatives concludes in good faith that a resolution does not appear likely. At that time the dispute shall be settled only by mediation and, if necessary, legally binding arbitration in accordance with the Rules of Procedure for Christian Conciliation of the Institute for Christian Conciliation, (complete text of the Rules is available at In that case, Judgment upon an arbitration award may be entered by any court having competent jurisdiction, in conformity with the laws of the Commonwealth of Virginia.

Emergency Contact Information

Phone: (H) (W) (C)  

Participant: I, , age 18 or older as an adult, have read this release of liability and assumption of risk agreement and fully understand and voluntarily agree to its terms including the high risk activities wavier and assumption as indicated by my signature below.

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Signature Certificate
Document name: Participant Release of Liability and Assumption of Risk Agreement (Adult High Risk)
lock iconUnique Document ID: 23c98a67d1c518a36714d46931c592622680c0ba
Timestamp Audit
February 10, 2020 12:18 pm ESTParticipant Release of Liability and Assumption of Risk Agreement (Adult High Risk) Uploaded by Cornerstone Chapel - IP