MISSION | MEDIA | MEMBERSHIP | FORMS | CALENDAR | CONTACT | PRAYER

Phone (________)________________________

Birth Date____/____/______Age________Grade_______School___________________

E-mail______________________________

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Address______________________________________________City______________

I, the undersigned, (hereinafter referred to as the “Undersigned”) do agree to indemnify
Creation Skatepark upon the reception of this Acknowledgement/ Agreement/ Waiver/ Assumption
of Risk agreement to indemnify (hereinafter referred to as the “ Agreement “) and hereby grant
permission to the above named person to participate (hereinafter “ Participant “) in the extreme
sports of Creation Skatepark (hereinafter “SK8”) subject to the following conditions, requirements
and agreement:
Creation Skatepark Emergency Medical/ Dental Release and Consent Agreement
1) The Undersigned does hereby authorize Creation Skatepark Staff to consent to IMMEDIATE FIRST
AID MEDICAL CARE, any X-ray, examination, anesthetic, medical, dental, or surgical diagnosis or
treatment and hospital care for the Participant (named on the reverse side of this form) which is deemed
advisable by and to the rendered under the general or special supervision of any physician or surgeon,
licensed under the provision of the Medicine Practice Act or any dentist incensed under the Dental Practice
Act, at any hospital, dental office, or elsewhere.
2) I understand that my insurance and / or my finances will cover any such treatment, and SK8 will
not be liable whether or not I am insured.
3) I understand that the Participant will be taken to the below stated hospital (if specified) by car
by SK8 Staff or Ambulance if a SK8 Staff person believes that the Participant may need medical / dental
attention only when the incident occurs within the city limits of the Kernersville area. I understand that
incidents, accidents, physical / medical, and dental emergencies which occur on retreats, camps, outings,
trips, and activities outside the Kernersville city limits will be treated at a nearby hospital or medical/ dental
facility whether or not my insurance applies at such a facility and I assume total responsibility for payment
of all such services.
4) It is understood that an effort shall be made to contact the Undersigned prior to rendering treatment
to the Participant, but that any of the above treatment will not be withheld if the Undersigned is not reached.
5) I, the Undersigned do hereby authorize SK8 to act as my agent in presenting this agreement to any
qualified medical/ dental practitioners and I will not hold SK8 liable for treatments rendered.
6) I also give permission for the authorized SK8 staff to administer medication the Participant has to take.
I will provide the authorized SK8 staff with this medication in the original container with specified written
instructions on the container for it’s dispensing.
7) This authorization will remain effective whether the Participant is in route to or from, participating,
observing, or standing by any program or activity of SK8 unless previously revoked by the Undersigned in
writing and delivered by any program or activity of SK8 unless previously revoked by the Undersigned in
writing and delivered by registered mail to SK8.
8) I understand that it is my responsibility to inform in writing the SK8 staff in the case that the Participant’s
information, insurance carrier, specified local hospital, or medical / physical conditions changes.
1) Does the Participant have any allergies to medicine or medical / physical conditions which the SK8 staff
or medical / dental professionals should be aware of?

Yes. Please explain. ____________________________________________________________________
No.
2) Does the Participant have medical insurance?
Yes. Insurance Co._____________________________________________________Policy #______________No.
3) Winston-Salem/ Forsyth Co. hospital (open 24 hours / where participants insurance is accepted.)
Any Local Hospital
Specific Local Hospital___________________________________________________________________
4) Emergency contact other than parent / legal guardian:

Name__________________________Phone(_______)_____________Relationship__________________
5) Under the penalty of perjury, the Undersigned does warrant to SK8 that all the information given on this
form is true, current and accurate.
6) I, as the parent/ legal guardian of the Participant have read, understand and consent to the terms
above.
6) I as the adult Participant have read, Understand and consent to the terms above and to the minor terms above.
Becoming a Participant.

X______________________Date____/____/____
Birth Parent / Legal guardian Signature

X____________________________________Date____/____/____
Skater Age 18 or older / Adult Participant Signature

Relationship___________________________

Print Name_______________________________________________Address__________________________

City_______________________________State______Zip__________E-mail__________________________