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MEDICAL RELEASE FORM

Today's Date: October 16, 2018

This medical release form is applicable to all Liberty Cheer All-Star & Tumbling LLC classes and events.

Acknowledgement of Risk , Waiver of Liability, Medical Authorization

As in all athletic activities, there is an inherent risk to injury. I do herby on behalf of myself and my child, release and forever discharge Liberty Cheer ALL Stars & Tumbling LLC organization, hosting facility, its principals, partners, members,managers, employees, officers, contractors, consultants,advisors, volunteers and agents from all claims, demands, and causes of action for injury to persons or property arising from participating in the event/class. I also understand that first aid will be rendered and/or if necessary or instructed to do so, give my permission to take my child to such a place as may be necessary for proper care and treatment.I grant permission to any hospital or clinic staff member to administer immediate treatment if necessary.

By granting permission for my child to participate in on the above mentioned events or classes, I assume full responsibility for said participants personal safety and release the above mentioned hosts from any and all liabilities that may occur from injury, including death to said participant that may arise from participating in this event/practice. I understand that these activities can result in serious injury and disability. I assume all responsibility , waive any claim for compensation for accidental injury, disability or death while attending the event/class, and herby hold harmless the host company, staff and hosting facility. Additionally, I herby agree to individually provide for all future medical expenses which may be incurred by my child as a result of any injury sustained while participating at or for Liberty Cheer All Stars & Tumbling.

I have read and understand this document and agree that my child will follow the rules that pertain to the event/class. I further attest that and acknowledge that my child is in good physical health and physically able to participate. I understand that may child may be photographed, filmed, or videotaped during event/class. I give permission for video and or photographs of my child or myself to be used for promotional purposes for these events/classes.

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information

Registration Date: *

Class/Team Attending: *

Grade/School: *

Students Cell#:

Please list any medical conditions we should be aware of:

Allergies:

How did you hear about us?

Physicians Name: *
First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information

Registration Date: *

Class/Team Attending: *

Grade/School: *

Students Cell#:

Please list any medical conditions we should be aware of:

Allergies:

How did you hear about us?

Physicians Name: *
Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information

Registration Date: *

Class/Team Attending: *

Grade/School: *

Students Cell#:

Please list any medical conditions we should be aware of:

Allergies:

How did you hear about us?

Physicians Name: *
Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information

Registration Date: *

Class/Team Attending: *

Grade/School: *

Students Cell#:

Please list any medical conditions we should be aware of:

Allergies:

How did you hear about us?

Physicians Name: *
Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information

Registration Date: *

Class/Team Attending: *

Grade/School: *

Students Cell#:

Please list any medical conditions we should be aware of:

Allergies:

How did you hear about us?

Physicians Name: *
Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information

Registration Date: *

Class/Team Attending: *

Grade/School: *

Students Cell#:

Please list any medical conditions we should be aware of:

Allergies:

How did you hear about us?

Physicians Name: *
Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information

Registration Date: *

Class/Team Attending: *

Grade/School: *

Students Cell#:

Please list any medical conditions we should be aware of:

Allergies:

How did you hear about us?

Physicians Name: *
Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information

Registration Date: *

Class/Team Attending: *

Grade/School: *

Students Cell#:

Please list any medical conditions we should be aware of:

Allergies:

How did you hear about us?

Physicians Name: *
Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information

Registration Date: *

Class/Team Attending: *

Grade/School: *

Students Cell#:

Please list any medical conditions we should be aware of:

Allergies:

How did you hear about us?

Physicians Name: *
Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information

Registration Date: *

Class/Team Attending: *

Grade/School: *

Students Cell#:

Please list any medical conditions we should be aware of:

Allergies:

How did you hear about us?

Physicians Name: *
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.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Insurance

Insurance Carrier*

Insurance Policy Number*
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*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Registration Date: *

Class/Team Attending: *

Grade/School: *

Students Cell#:

Please list any medical conditions we should be aware of:

Allergies:

How did you hear about us?

Physicians Name: *
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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