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Circus Class Registration, Hospital and Model Release Form

Name of Class: Zoppe Circus Camp 2021

In the event that emergency medical attention is needed for my son/daughter, I understand that Phoenix Youth Circus Arts and Zoppé Family Inc will make every effort to contact me immediately. In the event that I cannot be reached, I release medical authorization to Phoenix Youth Circus Arts and Zoppé Family Inc and its employees to obtain the necessary emergency medical attention for my son/daughter until I am reached.

I have read this Consent and Release and fully understand and consent to the above.

 

Phoenix Youth Circus Arts and Zoppé Family Inc
Participant Agreement, Release, Assumption of Risk, Hospital, and Model 
Release

In consideration of the services of Phoenix Youth Circus Arts and Zoppé Family Inc, their agents, owners, officers, volunteers, participants, employees, and all other persons or entities acting in any capacity on their behalf (hereinafter collectively referred to as “PYCA/ZFI/ZFI"), I hereby agree to release, indemnify, and discharge PYCA/ZFI, on behalf of myself, my spouse, my children, my parents, my heirs, assigns, personal representative and estate as follows:

1. I acknowledge that taking a clinic in circus skills entails known and unanticipated risks that could result in physical or emotional injury, paralysis, death, or damage to myself, to property, or to third parties. I understand that while safety of participants will always be a primary concern of PYCA/ZFI, circus activities entail certain risks that simply cannot be eliminated without jeopardizing the essential qualities of the activity. Without a certain degree of risk, circus students would not improve their skills, and the enjoyment of the activities would be diminished.

The risks include, among other things: Circus activities expose its participants to the usual risk of cuts and bruises. Other more serious risks exist as well. Participants can fall off equipment, sprain or break wrists and ankles, and can suffer more serious injuries as well. In any event, if you or your child is injured, you or your child may require medical assistance, at your own expense. Furthermore, PYCA/ZFI employees have difficult jobs to perform. They seek safety, but they are not infallible. They might be unaware of a participant's fitness or abilities. They may give incomplete warnings or instructions, and the equipment being used might malfunction.

2. I expressly agree and promise to accept and assume all of the risks existing in this activity. My participation in this activity is purely voluntary, and I elect to participate in spite of the risks.

3. I hereby voluntarily release, forever discharge, and agree to indemnify and hold harmless PYCA/ZFI from any and all claims, demands, or causes of action, which are in any way connected with my participation in this activity or my use of PYCA/ZFI's equipment or facilities.

4. Should PYCA/ZFI or anyone acting on their behalf, be required to incur attorney's fees and costs to enforce this agreement, I agree to indemnify and hold them harmless for all such fees and costs.

5. I certify that I have adequate insurance to cover any injury or damage I may cause or suffer while participating, or else I agree to bear the costs of such injury or damage myself. I further certify that I am willing to assume the risk of any medical or physical condition I may have.

6. In the event that I file a lawsuit against PYCA/ZFI, I agree to do so solely in the state of Arizona, and I further agree that the substantive law of Arizona 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 document shall remain in full force and effect.

In the event that emergency medical attention is needed for my son/daughter, I understand that Phoenix Youth Circus Arts and its employees will make every effort to contact me immediately. In the event that I cannot be reached, I release medical authorization to Phoenix Youth Circus Arts and its employees to obtain the necessary emergency medical attention for my son/daughter until I am reached.

By signing this form, you are granting Phoenix Youth Circus Arts the right to photograph and otherwise record and use you/your child’s picture, silhouette and other reproductions of their physical likeness, and voice recording (as the same may appear in any still camera photograph and/or video, motion picture film, or television program), in and with the exhibition, theatrically, on television or otherwise in any other medium, of any video, motion picture or television program in which they may be used or incorporated, and also in advertising or publicizing of the same.

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 PYCA/ZFI 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.


Date signed: August 19, 2022

First Participant's Name

First Name*

Middle Name

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

Grade

Physician's Name:

Phone Number:

Insurance Company:

Click to customize text box label

Group Number:

Member Number:

Student has the following pre-existing medical conditions:

Student takes the following medications:

Student is allergic to the following medicines:

Student is allergic to the following foods:

Additional comments or conditions that Circus Arts Teachers should be aware of:

I have read this Consent and Release and fully understand and consent to the above. 
 

First Participant's Signature*
Second Participant's Name

First Name*

Middle Name

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

Grade

Physician's Name:

Phone Number:

Insurance Company:

Click to customize text box label

Group Number:

Member Number:

Student has the following pre-existing medical conditions:

Student takes the following medications:

Student is allergic to the following medicines:

Student is allergic to the following foods:

Additional comments or conditions that Circus Arts Teachers should be aware of:

I have read this Consent and Release and fully understand and consent to the above. 
 

Third Participant's Name

First Name*

Middle Name

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

Grade

Physician's Name:

Phone Number:

Insurance Company:

Click to customize text box label

Group Number:

Member Number:

Student has the following pre-existing medical conditions:

Student takes the following medications:

Student is allergic to the following medicines:

Student is allergic to the following foods:

Additional comments or conditions that Circus Arts Teachers should be aware of:

I have read this Consent and Release and fully understand and consent to the above. 
 

Fourth Participant's Name

First Name*

Middle Name

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

Grade

Physician's Name:

Phone Number:

Insurance Company:

Click to customize text box label

Group Number:

Member Number:

Student has the following pre-existing medical conditions:

Student takes the following medications:

Student is allergic to the following medicines:

Student is allergic to the following foods:

Additional comments or conditions that Circus Arts Teachers should be aware of:

I have read this Consent and Release and fully understand and consent to the above. 
 

Fifth Participant's Name

First Name*

Middle Name

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

Grade

Physician's Name:

Phone Number:

Insurance Company:

Click to customize text box label

Group Number:

Member Number:

Student has the following pre-existing medical conditions:

Student takes the following medications:

Student is allergic to the following medicines:

Student is allergic to the following foods:

Additional comments or conditions that Circus Arts Teachers should be aware of:

I have read this Consent and Release and fully understand and consent to the above. 
 

Sixth Participant's Name

First Name*

Middle Name

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

Grade

Physician's Name:

Phone Number:

Insurance Company:

Click to customize text box label

Group Number:

Member Number:

Student has the following pre-existing medical conditions:

Student takes the following medications:

Student is allergic to the following medicines:

Student is allergic to the following foods:

Additional comments or conditions that Circus Arts Teachers should be aware of:

I have read this Consent and Release and fully understand and consent to the above. 
 

Seventh Participant's Name

First Name*

Middle Name

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

Grade

Physician's Name:

Phone Number:

Insurance Company:

Click to customize text box label

Group Number:

Member Number:

Student has the following pre-existing medical conditions:

Student takes the following medications:

Student is allergic to the following medicines:

Student is allergic to the following foods:

Additional comments or conditions that Circus Arts Teachers should be aware of:

I have read this Consent and Release and fully understand and consent to the above. 
 

Eighth Participant's Name

First Name*

Middle Name

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

Grade

Physician's Name:

Phone Number:

Insurance Company:

Click to customize text box label

Group Number:

Member Number:

Student has the following pre-existing medical conditions:

Student takes the following medications:

Student is allergic to the following medicines:

Student is allergic to the following foods:

Additional comments or conditions that Circus Arts Teachers should be aware of:

I have read this Consent and Release and fully understand and consent to the above. 
 

Ninth Participant's Name

First Name*

Middle Name

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

Grade

Physician's Name:

Phone Number:

Insurance Company:

Click to customize text box label

Group Number:

Member Number:

Student has the following pre-existing medical conditions:

Student takes the following medications:

Student is allergic to the following medicines:

Student is allergic to the following foods:

Additional comments or conditions that Circus Arts Teachers should be aware of:

I have read this Consent and Release and fully understand and consent to the above. 
 

Tenth Participant's Name

First Name*

Middle Name

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

Grade

Physician's Name:

Phone Number:

Insurance Company:

Click to customize text box label

Group Number:

Member Number:

Student has the following pre-existing medical conditions:

Student takes the following medications:

Student is allergic to the following medicines:

Student is allergic to the following foods:

Additional comments or conditions that Circus Arts Teachers should be aware of:

I have read this Consent and Release and fully understand and consent to the above. 
 

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.
Parent/Guardian Contact Number

Home Phone:

Work Phone:

Cell Phone: *
Emergency Contact (This person will be called if Parent/Guardian cannot be reached):

Name: *

Relation to Student: *

Home Phone:

Work Phone:

Cell Phone: *
In consideration of the minor ("Minor") being permitted by PYCA/ZFI to participate in its activities and to use its equipment and facilities, I further agree to indemnify and hold harmless PYCA/ ZFI 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.

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*

Middle Name

Last Name*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Grade

Physician's Name:

Phone Number:

Insurance Company:

Click to customize text box label

Group Number:

Member Number:

Student has the following pre-existing medical conditions:

Student takes the following medications:

Student is allergic to the following medicines:

Student is allergic to the following foods:

Additional comments or conditions that Circus Arts Teachers should be aware of:

I have read this Consent and Release and fully understand and consent to the above. 
 

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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