ANNUAL DAILY ACTIVITIES

FORM

Personal Information □ Staff □

Student
Full name
Address

Phone
E-mail address
Date of Birth (MM/DD/YYYY)
College/School/Church Affiliation

Auto/Driver Information
Drivers’ License Number & State
Insurance Company
Policy Number
Liability Limits
Business phone

Emergency and Medical Information

In case of emergency, contact
Emergency contact’s address
Emergency contact’s phone
Doctor’s name
Doctor’s phone
Doctor’s address
Medical insurance carrier and
member number
Blood type

Known medical conditions

Known allergies

Current medications

Form Number 2005-1

Revision Date: 09.14.05 Page 1 of 2
Activities (NO OVERNIGHT)
‫ ٱ‬Daily Outings ‫ ٱ‬Pool Parties
‫ ٱ‬Independent Sports ‫ ٱ‬Daily Hiking
‫ ٱ‬Rope Courses ‫ ٱ‬Day Retreat
‫ ٱ‬Other ___________________________________
___________________________________
___________________________________
I understand and acknowledge that the activity (ies) I am to voluntarily engage in as a participant and/or
volunteer bears certain known risks and unanticipated risks which could result in injury, death, illness or
disease, physical or mental, or damage to me, to my property, or to spectators or other third parties.
Being aware that this activity entails known and unknown risk of injury to myself and a risk of injury to
spectators or third parties as a result of my actions, I expressly agree, covenant and promise to accept and
assume all responsibility and risk of injury, death, illness or disease, or damage to myself, to others, or to
my property arising from my participation in these activities. My participation in these activities is purely
voluntary, no one is forcing me to participate, and I elect to participate in spite of the risks. I have been
adequately informed to make this decision.
I hereby voluntarily release, forever discharge, and agree to hold harmless and indemnify the Coalition for
Christian Outreach (CCO), its officers, employees, agents, or representatives, and all other persons or
entities from any and all liability, claims, demands, actions, or rights of actions, which are related to, arise
out of, or are in any way connected with my participation in these activities, including specifically, but not
limited to, the negligent acts or omissions of the CCO, its officers, employees, agents or representatives and
all other persons and entities for any and all injury, death, illness or disease, and damage to myself or to my
property. IN SIGNING THIS DOCUMENT, I FULLY RECOGNIZE THAT IF ANYONE IS HURT
OR PROPERTY IS DAMAGED WHILE I AM ENGAGED IN ANY EVENT, I WILL NOT HAVE
THE RIGHT TO MAKE A CLAIM OR FILE A LAWSUIT AGAINST THE CCO, OR ITS
OFFICERS, AGENTS OR EMPLOYEES, EVEN IF THEY OR ANY OF THEM NEGLIGENTLY
CAUSED THE BODILY INJURY OR PROPERTY DAMAGE.
Should it become necessary for the CCO, or someone on the CCO’s behalf, to incur attorney’s fees and
costs to enforce this agreement, or any portion thereof, I agree to pay all reasonable cost and attorney’s fees
thereby expended, or for which liability is incurred
I certify that I have sufficient health, accident and liability insurance to cover any bodily injury or property
damage I may incur while participating in these activities and to cover bodily injury or property damage
caused to a third party as a result of my participation in these activities. If I have no such insurance, I
certify that I am capable of personally paying for any and all such expenses or liability.

My signature below indicates that I have read this entire document, understand it
completely, understand that it affects my legal rights and agree to be bound by its terms.

Signature of Participant: ________________________________________

Signature of Parent/Legal Guardian
(If Applicant is under 18 years of age) ____________________________________________
Print Name: ________________________________________
Address: ________________________________________
________________________________________
Phone: ___________________ Date: ___________
THIS FORM IS TO BE COMPLETED ANNUALLY

Form Number 2005-1

Revision Date: 09.14.05 Page 2 of 2