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MEDICAL RELEASE FORM

Today's Date: September 20, 2019

Acknowledgement of Risk, Waiver of Liability, Medical Authorization

 

Notice: This is a legally binding contract. In consideration of me or my child being permitted by Liberty Cheer ALL Stars and Tumbling LLC Allstars to participate in the activities, both in classes and non- structured activity, any program offered by Liberty Cheer ALL Stars and Tumbling LLC (“Liberty”), I agree to the following waiver and release and I make the following representations myself and any minor child who is under my custody and control.  (Any reference to I or myself will also include any adult signing the agreement for a minor):

1. I HEREBY ACKNOWLEDGE THE INHERENT EXTREME RISKS IN PERFORMING THE GYMNASTICS, TUMBLING AND CHEER ACTIVITIES. I realize that those risks include, but are not limited to: any aerial activity, falls from the equipment, inattention or actions of other gymnasts, misuse of equipment, holds which may become loose or damaged, and freakish accidents which cannot be foreseen. I acknowledge that the above list is not inclusive of all possible risks associated with the use of the facilities, and/or the sport of climbing and I agree that said list in no way limits the extent or reach of this release. I VOLUNTARILY ASSUME ALL SUCH RISKS WITH FULL KNOWLEDGE AND APPRECIATION OF THE DANGER AND RISK INV
OLVED.

 

2. By granting permission for my child to participate in any of the activities held, I voluntarily agree to assume all risk of personal injury, including death and disability, that may occur while I am in the facility or participating in an event or program or while I am tumbling, cheering or performing other gymnastics anywhere at any time whether under supervision of Liberty personnel. I hereby knowingly and intentionally waive and release, and agree to indemnify, hold harmless and defend Liberty, its successors, assigns, officers, employees, wall designers and builders, hold manufacturers, lessors, affiliated organizations and agents from all liability for any such damage, injury, paralysis or death which may result of my actions, whether the injury is to myself or another participant. THIS RELEASE SHALL BE EFFECTIVE EVEN THOUGH SAID LOSS, DAMAGE, OR INJURY RESULTS OR HAS RESULTED FROM THE NEGLIGENCE, WRONGFUL ACTS, OMISSIONS, BREACH OF WARRANTY OR STRICT TORT LIABILITY OF LIBERTY CHEER ALL STARS AND TUMBLING LLC OR THE OTHER PARTIES RELEASED.

3. I also grant permission for Liberty staff to render first aid when necessary as well as permission to transport my child to a medical service provider if such first aid is not sufficient.  As it may be necessary for some of the personal medical information to be disseminated for proper care, I hereby waive any complaint or liability for Allstar’s use and knowledge of personal medical information when rendering first aid or having a third party medical provider deliver care.  I indemnify Liberty from any possible violation of healthcare laws including, but \not limited to HIPAA. 

4. I am at least 18 years of age and otherwise legally competent to sign this agreement. This release shall be effective and binding upon me and my assigns, heirs, representatives, executors and administrators. If under the age of 18, this release must be signed by the parent/guardian of the minor, and I agree to indemnify and hold harmless Liberty Cheer ALL Stars and Tumbling LLC and other released parties stated above.  I UNDERSTAND THAT THIS RELEASE IS A CONTRACT. No oral representations, statements or inducements apart from the above written agreement have been made. I expressly state that I have read, understand and am familiar with all its provisions and that I sign it of my own free will. I further expressly agree that this release, waiver and indemnification agreement is intended to be as broad and inclusive as is permissible by the laws of the State of Texas and that if any portion of this agreement is held to be invalid, it is agreed that the balance shall, notwithstanding, continue in full force and effect.
I HAVE HAD SUFFICIENT OPPORTUNITY TO READ THIS ENTIRE DOCUMENT. I HAVE READ AND UNDERSTOOD IT, AND I AGREE TO BE BOUND BY ITS TERMS. 

 

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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