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Minnesota Xtreme All Star Cheer 

Liabilty Waiver and Appearance Clause

Minnesota Xtreme Waiver Medical Release

  • I give my approval for the above named student’s participation in any and all activities of the program.
  • I hereby forever waive, release and discharge, Minnesota Xtreme All Star Cheer, Inc. (hereafter referred to as “MXAC”), their officers, directors, employees, and agents from all liability for any and all damages and injuries suffered by the participant in connection with said use of the aforementioned equipment, instructors, and facilities.
  • As a student, or parent or guardian of a student, that is my option to consult a physician for assurance of proper health and have been encouraged to do so by MXAC.
  • I authorize the representatives of MXAC to provide any emergency medical services that may be required due to an injury during any gymnastics activity at or for MXAC.
  • I understand and acknowledge that the activity my child is about to engage in poses known risks and unanticipated risks which could result in injury, paralysis death, emotional distress, or damage to my child, to property, or to third parties. The following describes some, but not all, of those risks: Gymnastics and cheerleading entails certain risks that simply cannot be eliminated without jeopardizing the essential qualities of the activity. Without a certain degree of risk, gymnastics and cheerleading students would not improve their skills, and the enjoyment of the sport would be diminished. Gymnastics and cheerleading exposes its participants to the usual risk of cuts and bruises. Other more serious risks exist as well. Traveling to and from shows, competitions, and exhibitions raises the possibility of any manner of transportation accidents. In any event, if you child is injured, your child may require medical assistance, at your own expense.
  • I certify that my child has health, accident, and liability insurance to cover any bodily injury or property damage that may be caused or suffered while participating in this event or activity, or else I agree to bear the costs of such injury or damage to my child. I further certify that I am willing to assume the risk of any medical or physical condition that my child may have or else I am willing to assume and bear the costs of all risks that may be created, directly or indirectly, by any such condition.
  • MXAC is not responsible, whatsoever, for anything that happens before or after the student’s designated class, camp, clinic, birthday party, open gym, or sleep-over time.
  • Should MXAC, or anyone acting on their behalf, be required to incur attorney’s fees and costs to enforce this agreement, I agree to indemnify and reimburse them for such fees and costs.
  • In the event that I file a lawsuit against MXAC, I agree to do so solely in the state of Minnesota, and I further agree that the substantive law of that state shall apply in that action without regard to the conflict of law rules of that state. I agree that if any portion of this agreement is found to be void or unenforceable, the remaining portions shall remain in full force and effect.
  • By signing this document, I acknowledge that if anyone is hurt or property is damaged during my participation in this activity, I may be found by a court of law to have waived my right to maintain a lawsuit against MXAC on the basis of any claim from which I have released them herein.

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.   

I Agree

Signature: 

Date: January 15, 2019

Appearance Clause

I understand that Minnesota Xtreme All Star Cheer, Inc. produces promotional material about their programs. I understand that my son/daughter may be included in video tape or photography taken during classes and/or events, and I hereby grant MXAC, its successors, assignees, licenses, sponsors, any television networks, and all other commercial exhibitors the exclusive right to photograph and/or video tape my son/daughter and further to utilize my son/daughter’s name, face, likeness, voice, and appearance as part of the event/class/etc., and in advertising and promotion of the event/class/etc. without reservation or limitation. In granting this license, I understand that Minnesota Xtreme All Star Cheer, Inc. is under no obligation to exercise any of its rights, licenses, and/or privileges herein granted.

I have read and agree to the above Appearance Clause.  

I Agree
 

Signature: 

Date: January 15, 2019

First Participant's Name

First Name*

Last Name*

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

How did you hear about us? *

School: *

Grade (2017-2018):

Medical Information 

Heart condition or disease?*
Diabetes?*
Convulsions disorder?*
Asthma?*
Allergic to medication?*
Allergic to insect sting?*

Allergies

Additional Medical Information
First Participant's Signature*
Second Participant's Name

First Name*

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

How did you hear about us? *

School: *

Grade (2017-2018):

Medical Information 

Heart condition or disease?*
Diabetes?*
Convulsions disorder?*
Asthma?*
Allergic to medication?*
Allergic to insect sting?*

Allergies

Additional Medical Information
Third Participant's Name

First Name*

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

How did you hear about us? *

School: *

Grade (2017-2018):

Medical Information 

Heart condition or disease?*
Diabetes?*
Convulsions disorder?*
Asthma?*
Allergic to medication?*
Allergic to insect sting?*

Allergies

Additional Medical Information
Fourth Participant's Name

First Name*

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

How did you hear about us? *

School: *

Grade (2017-2018):

Medical Information 

Heart condition or disease?*
Diabetes?*
Convulsions disorder?*
Asthma?*
Allergic to medication?*
Allergic to insect sting?*

Allergies

Additional Medical Information
Fifth Participant's Name

First Name*

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

How did you hear about us? *

School: *

Grade (2017-2018):

Medical Information 

Heart condition or disease?*
Diabetes?*
Convulsions disorder?*
Asthma?*
Allergic to medication?*
Allergic to insect sting?*

Allergies

Additional Medical Information
Sixth Participant's Name

First Name*

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

How did you hear about us? *

School: *

Grade (2017-2018):

Medical Information 

Heart condition or disease?*
Diabetes?*
Convulsions disorder?*
Asthma?*
Allergic to medication?*
Allergic to insect sting?*

Allergies

Additional Medical Information
Seventh Participant's Name

First Name*

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

How did you hear about us? *

School: *

Grade (2017-2018):

Medical Information 

Heart condition or disease?*
Diabetes?*
Convulsions disorder?*
Asthma?*
Allergic to medication?*
Allergic to insect sting?*

Allergies

Additional Medical Information
Eighth Participant's Name

First Name*

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

How did you hear about us? *

School: *

Grade (2017-2018):

Medical Information 

Heart condition or disease?*
Diabetes?*
Convulsions disorder?*
Asthma?*
Allergic to medication?*
Allergic to insect sting?*

Allergies

Additional Medical Information
Ninth Participant's Name

First Name*

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

How did you hear about us? *

School: *

Grade (2017-2018):

Medical Information 

Heart condition or disease?*
Diabetes?*
Convulsions disorder?*
Asthma?*
Allergic to medication?*
Allergic to insect sting?*

Allergies

Additional Medical Information
Tenth Participant's Name

First Name*

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

How did you hear about us? *

School: *

Grade (2017-2018):

Medical Information 

Heart condition or disease?*
Diabetes?*
Convulsions disorder?*
Asthma?*
Allergic to medication?*
Allergic to insect sting?*

Allergies

Additional Medical Information
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 news, promotions and discounts by e-mail.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Additional Information

In the event of an emergency occurring while my son/daughter is at a Minnesota Xtreme, I grant my permission to Minnesota Xtreme and its employees to take whatever action necessary. In the event that I cannot be reached, I hereby authorize Minnesota Xtreme and/or its employees to give consent for my son/daughter, to receive medical treatment. 


Insurance Company: *

Policy Number *
Parent Information

Guardian\Mother's Name: *

Guardian\Mother's Email: *

Guardian\Mother's Work #:

Guardian\Mother's Cell #: *

Guardian\Father's Name: *

Guardian\Father's Email: *

Guardian\Father's Work #:

Guardian\Father's Cell #: *
Account information should be sent to:*
In consideration of (“Minor”) being permitted by Minnesota Xtreme All Star Cheer to participate in its activities and to use its equipment and facilities, I further agree to indemnify and hold Minnesota Xtreme All Star Cheer from any and all claims which are brought by, or on behalf of Minor and which are in any way connected with such use or participation by Minor.
Parent or Guardian's Name

First Name*

Last Name*

Relationship*

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

How did you hear about us? *

School: *

Grade (2017-2018):

Medical Information 

Heart condition or disease?*
Diabetes?*
Convulsions disorder?*
Asthma?*
Allergic to medication?*
Allergic to insect sting?*

Allergies

Additional Medical Information
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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