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MEDICAL INFORMATION / AUTHORIZATION OF TREATMENT 

AND

RELEASE OF LIABILITY WAIVER 

MEDICAL INFORMATION / AUTHORIZATION OF TREATMENT 

Medical Treatment Authorization and Additional Waiver, Release of Liability and Agreement to Indemnify and Hold Harmless and to Defend

I understand that there are risks of physical injury associated with, arising out of and inherent to the activity of cheerleading/tumbling/dance. In recognition of this acknowledged risk of injury, I knowingly and voluntarily waive all rights and/or causes of action of any kind, including any and all claims of negligence, arising as a result of such activity from which liability could accrue to K & M Uyetake Enterprises, Inc., its officers, agents, employees, instructors, owners and all affiliated entities (hereinafter collectively referred to as “Utah Xtreme Cheer”). In addition, I authorize Utah Xtreme Cheer to provide preliminary medical treatment in the event of injury and agree to release and hold Utah Xtreme Cheer harmless from claims arising out of or related to such treatment. I waive all rights and/or causes of action of any kind, including any and all claims of negligence, arising as a result of such treatment.

Furthermore, I agree to indemnify, hold harmless and to defend Utah Xtreme Cheer from and against any and all liabilities, claims, demands, suits or judgments or costs including attorney’s fees incurred or initiated in connection with Utah Xtreme Cheer’s preliminary medical treatment or my use of any facilities owned or operated by Utah Xtreme Cheer or presence thereon, including, but not limited to pain and suffering, economic injuries, illness, paralysis, death, damages of any kind or economic or emotional loss, that I may suffer as a direct or indirect result of my use of the Facilities. Such waiver, release and indemnity agreements are also governed by that certain Waiver, Release of Liability and Agreement to Indemnify and Hold Harmless and to Defend entered into by Utah Xtreme Cheer and me (“Waiver”). I represent and warrant that I have executed the Waiver or will do so before participating in any activities held in facilities owned or operated by Utah Xtreme Cheer.

I am aware that this is an authorization of medical treatment and release of liability and acknowledgment of my voluntary and knowing assumption of risk of injury. I have signed this document voluntarily of my own free will in exchange for the privilege of participation.

I warrant the above information is complete and correct. I hereby authorize the Utah Xtreme Cheer owners to act in my behalf to provide emergency medical treatment. I further release Utah Xtreme Cheer of all liabilities associated with my attendance at Utah Xtreme Cheer gym. 

 

If your child is a minor, please read below:

As the parent or guardian of the minor named above (the "Minor"), I hereby make and enter into each and every agreement, representation, waiver, and release described above on behalf of myself, the Minor, and any other parent or guardian of the minor named above, intending that they be binding upon me, the Minor, and our respective heirs, executors, administrators, and assigns. I intend to give up my right, the Minor's right, and the right of any other parent or guardian to maintain any claim or suit against Utah Xtreme Cheer (as defined above) arising out of the minor's participation in any activities involving Utah Xtreme Cheer (as defined above) in any way. I represent and warrant that I HAVE LEGAL AUTHORITY TO MAKE THESE AGREEMENTS, REPRESENTATIONS, WAIVERS AND RELEASES, AND I AGREE TO DEFEND, HOLD HARMLESS, AND INDEMNIFY Utah Xtreme Cheer from and against any and all liability arising out of any lack of authority on my part to legally bind the Minor, or any unenforceability for any reason of the above agreements, representations, waivers, and releases made by or on behalf of the Minor. 

 

 

 

 

WAIVER, RELEASE OF LIABILITY AND
AGREEMENT TO INDEMNIFY AND HOLD HARMLESS AND TO DEFEND

In consideration of being permitted to utilize the open gym, equipment, facilities and/or property (collectively, the “Facilities”) owned, operated or managed by K & M Uyetake Enterprises, Inc. (the “Gym”), the undersigned, on behalf of him/herself, his or her heirs, executors, administrators, assigns, personal representatives, knowingly and voluntarily enters into this Waiver, Release of Liability and Agreement to Indemnify and Hold Harmless and to Defend (hereafter the “Waiver”).

I hereby FOREVER RELEASE AND DISCHARGE Gym, its employees, managers, members, agents, attorneys, staff, volunteers, affiliates, representatives and assigns (the “Released Parties”), from any and all liabilities, claims, demands or causes of action that I may hereafter have for personal injuries, death or property damage arising out of my use of the Facilities, including but not limited to, (i) hidden, latent, or obvious defects, (ii) the negligence or omission, including any act, other than the willful misconduct, of any Released Party, and (iii) my failure to exercise due care. I hereby acknowledge that Gym owes no duty of care to keep the Facilities safe for entry or use or to give any warning regarding a dangerous condition, use, structure or activity on the property or Facilities.

I am fully aware of all of the risks associated with entering the property and utilizing the Facilities. I am qualified, in good health and in proper physical condition to participate in activities held at the Facilities. I acknowledge that if I believe any conditions are unsafe at the Facilities, I will immediately discontinue participation in the relevant activity. I am utilizing the Facilities entirely at my own risk. I understand that physical or psychological injury, pain, suffering, illness, disfigurement, temporary or permanent disability, including paralysis, physical or emotional loss or death may occur. I further understand that I might suffer economic loss or damage to my personal property from using the Facilities. I knowingly accept all risks both known and unknown and whether caused by me or by another party, including, without limitation, negligence or misconduct. I understand that I am using the Facilities for my own benefit and that no representations, warranties, or guarantees related to the nature or condition of the Facilities has been made by the Gym or the Released Parties.

I agree never to institute any suit or action at law or otherwise and hereby instruct my heirs, executors and administrators never to institute any suit or action at law or otherwise against any Released Party nor to initiate any nor assist the prosecution of any claim for damages or cause of action which I, my heirs, executors or administrators may have by reason of injury or death to my person or property arising from the activities contemplated by this Waiver. I acknowledge that the breach of such covenant will cause substantial and irreparable harm to any Released Party named as a defendant to such lawsuit beyond the mere expense of defending the same and that such damages are difficult or impossible to estimate or ascertain with certainty.

I agree to indemnify, hold harmless and to defend the Released Parties from and against any and all liabilities, claims, demands, suits or judgments or costs including attorney’s fees incurred or initiated in connection with my use of the Facilities or presence thereon, including, but not limited to pain and suffering, economic injuries, illness, paralysis, death, damages of any kind or economic or emotional loss, that I may suffer as a direct or indirect result of my use of the Facilities.

I further agree to promptly repair, restore, replace or pay all costs to repair any damage to Gym or its property or Facilities caused by me or any other person or item under my control.

I agree that this Waver shall be construed in accordance with, and governed by the laws of the State of Utah. In addition, I agree that all litigation, mediation or arbitration for property damage, personal injury or related loss against any of the Released Parties must be brought and maintained in Salt Lake County, Utah. Further, I consent and agree that jurisdiction and venue for any litigation shall lie exclusively in state and federal courts located in Salt Lake County, Utah. In the event any portion of this Waiver is found to be unenforceable, the remaining terms shall be fully enforceable to the greatest extent permitted by law. 

 

If your child is a minor, please ready below:

As the parent or guardian of the minor named above (the "Minor"), I hereby make and enter into each and every agreement, representation, waiver, and release described above on behalf of myself, the Minor, and any other parent or guardian of the minor named above, intending that they be binding upon me, the Minor, and our respective heirs, executors, administrators, and assigns. I intend to give up my right, the Minor's right, and the right of any other parent or guardian to maintain any claim or suit against any of the Released Parties (as defined above) arising out of the minor's participation in any activities involving any of the Released Parties (as defined above) in any way. I believe and represent that I HAVE LEGAL AUTHORITY TO MAKE THESE AGREEMENTS, REPRESENTATIONS, WAIVERS AND RELEASES, AND I AGREE TO DEFEND, HOLD HARMLESS, AND INDEMNIFY the Released Parties from and against any and all liability arising out of any lack of authority on my part to legally bind the Minor, or any unenforceability for any reason of the above agreements, representations, waivers, and releases made by or on behalf of the Minor. 

 

Please select who will be participating...
AdultMinor
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First Participant's Name

First Name*

Middle Name

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Signature*
Participant's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail from Utah Xtreme Cheer.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Insurance

Insurance Carrier*

Insurance Policy Number*
Mother's Name
Mother's Phone Number
Father's Name
Father's Phone Number
Do you have any medial problems or allergies that may interfere with your classes? If yes, please list and describe. Also, do you have medication for this, with you? If you do not have nay problems or limitations, please say 'N/A'.
Have you ever had any serious illness, surgery, injury? If Yes, Please describe and give date(s). If none, please say 'N/A'.
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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