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This form is to be completed by the instructor or owner with every incident.  

Copy and paste the body of your waiver here.

First Instructor Name

First Name*

Last Name*

Phone*
First Instructor Date of Birth*
First Instructor Signature*
Second Instructor Name

First Name*

Last Name*
Second Instructor Date of Birth*
Third Instructor Name

First Name*

Last Name*
Third Instructor Date of Birth*
Fourth Instructor Name

First Name*

Last Name*
Fourth Instructor Date of Birth*
Fifth Instructor Name

First Name*

Last Name*
Fifth Instructor Date of Birth*
Sixth Instructor Name

First Name*

Last Name*
Sixth Instructor Date of Birth*
Seventh Instructor Name

First Name*

Last Name*
Seventh Instructor Date of Birth*
Eighth Instructor Name

First Name*

Last Name*
Eighth Instructor Date of Birth*
Ninth Instructor Name

First Name*

Last Name*
Ninth Instructor Date of Birth*
Tenth Instructor Name

First Name*

Last Name*
Tenth Instructor Date of Birth*
Parent or Guardian's Email Address

Email
Check to receive information, news, and discounts by e-mail.
Your signed waiver will be sent to the email address provided here and is available for download for three days via URL attachment.
Incident Details

Name of Participant

Parents Name & Phone number

Date & Time Incident Occurred: *
Was incident reported at the time of the incident?*
No
Yes
If a minor, Parent Notified at the time of the incident ?*
No
Yes

Date, Time & How you were notified of Incident *
Was their an injury?*
No
Yes

Describe Incident......Paint the picture...activities leading up to incident, description of incident, and injuries obtained. *
Medical Assistance needed?*
None needed
Follow up with Family Doctor recommendation given
Ambulance called
Other-provide details below

Other: After Incident care provided..... Example:band aide to scraped knee, parent notified and released into parents care.

Ways this incident could of been prevented *
If Injury occurred, Did you obtain pictures?*
No
Yes

If pictures were not obtained, why? *
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.


By signing below the parent or court-appointed legal guardian agrees that they are also 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 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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