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MEDICAL & LIABILITY RELEASE

Each participant MUST have one on file at competition site. 

I, the natural parent, legal guardian and/or Managing conservator of participant, do hereby acknowledge and state that said student is presently under my care, custody, and control, and that I possess the authority to grant the permission and authorization stated herein, and the student has no conditions which would prohibit or restrict his/her participation with the North Dakota Cheer Coach Association’s State Cheer Competitions. I give permission for my child to travel to the competition site and to compete in the NDCCA State Cheer Competition.


I hereby give my permission to the NDCCA to use any and all photographs taken at the NDCCA competition on their web site and other printed material.


I authorize any representative of the NDCCA Board of Directors to locate qualified and licensed medical personnel and/or transport said student to an appropriate medical facility in the event that it may become necessary.


I understand I will be notified as soon as possible in the event of an emergency. My insurance company and I will assume all expenses of such treatment. 


Date: January 3, 2025

First Athletes Name

First Name*

Middle Name

Last Name*
First Athletes Date of Birth*
First Athletes Information
Competition the athlete is completing the waiver for Fall or Winter*
Fall
Winter

Of Year of Competition *

(Complete School Name) *

NDCCA State Cheer Competition held in ________, North Dakota. *
First Athletes Signature*
Second Athletes Name

First Name*

Middle Name

Last Name*
Second Athletes Date of Birth*
Second Athletes Information
Competition the athlete is completing the waiver for Fall or Winter*
Fall
Winter

Of Year of Competition *

(Complete School Name) *

NDCCA State Cheer Competition held in ________, North Dakota. *
Third Athletes Name

First Name*

Middle Name

Last Name*
Third Athletes Date of Birth*
Third Athletes Information
Competition the athlete is completing the waiver for Fall or Winter*
Fall
Winter

Of Year of Competition *

(Complete School Name) *

NDCCA State Cheer Competition held in ________, North Dakota. *
Fourth Athletes Name

First Name*

Middle Name

Last Name*
Fourth Athletes Date of Birth*
Fourth Athletes Information
Competition the athlete is completing the waiver for Fall or Winter*
Fall
Winter

Of Year of Competition *

(Complete School Name) *

NDCCA State Cheer Competition held in ________, North Dakota. *
Fifth Athletes Name

First Name*

Middle Name

Last Name*
Fifth Athletes Date of Birth*
Fifth Athletes Information
Competition the athlete is completing the waiver for Fall or Winter*
Fall
Winter

Of Year of Competition *

(Complete School Name) *

NDCCA State Cheer Competition held in ________, North Dakota. *
Sixth Athletes Name

First Name*

Middle Name

Last Name*
Sixth Athletes Date of Birth*
Sixth Athletes Information
Competition the athlete is completing the waiver for Fall or Winter*
Fall
Winter

Of Year of Competition *

(Complete School Name) *

NDCCA State Cheer Competition held in ________, North Dakota. *
Seventh Athletes Name

First Name*

Middle Name

Last Name*
Seventh Athletes Date of Birth*
Seventh Athletes Information
Competition the athlete is completing the waiver for Fall or Winter*
Fall
Winter

Of Year of Competition *

(Complete School Name) *

NDCCA State Cheer Competition held in ________, North Dakota. *
Eighth Athletes Name

First Name*

Middle Name

Last Name*
Eighth Athletes Date of Birth*
Eighth Athletes Information
Competition the athlete is completing the waiver for Fall or Winter*
Fall
Winter

Of Year of Competition *

(Complete School Name) *

NDCCA State Cheer Competition held in ________, North Dakota. *
Ninth Athletes Name

First Name*

Middle Name

Last Name*
Ninth Athletes Date of Birth*
Ninth Athletes Information
Competition the athlete is completing the waiver for Fall or Winter*
Fall
Winter

Of Year of Competition *

(Complete School Name) *

NDCCA State Cheer Competition held in ________, North Dakota. *
Tenth Athletes Name

First Name*

Middle Name

Last Name*
Tenth Athletes Date of Birth*
Tenth Athletes Information
Competition the athlete is completing the waiver for Fall or Winter*
Fall
Winter

Of Year of Competition *

(Complete School Name) *

NDCCA State Cheer Competition held in ________, North Dakota. *
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
CONFIDENTIAL MEDICAL INFORMATION

(Family Physician) *

(Physicians Phone Number) *

(Insurance Company) *

(Insurance Policy Number) *

List pertinent medical information applicable to allergies, nervous disorders, heart trouble, diabetes, epilepsy, etc. (Diabetic pumps, heart monitors, braces, inhaler, etc.) Please put N/A if not applicable. *

Indicate any medication or drugs to which the participant is allergic. Please put N/A if not applicable. *

List any regular medication the participant is taking. Please put N/A if not applicable. *
(Is participant carrying any medication with them)*
Yes
No

List two other contacts in case of an emergency: 


Name *

Relationship to Child *

Phone Number *

Name *

Relationship to Child *

Phone 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.


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*

Relationship*

Phone*
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 Date of Birth*
Parent or Guardian's Information
Competition the athlete is completing the waiver for Fall or Winter*
Fall
Winter

Of Year of Competition *

(Complete School Name) *

NDCCA State Cheer Competition held in ________, North Dakota. *
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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