THE CHEER PITT, INC. RELEASE AND WAIVER OF LIABILITY AGREEMENT STUDENT INFORMATION NAME_________________________________________________________________AGE______D.O.B_____/_____/_____ GENDER ______ ADDRESS______________________________________________ CITY/STATE_______________________________ CELL #_________________________________ EMAIL___________________________________________________ PARENT/GUARDIAN 1 PARENT/GUARDIAN 2 NAME__________________________________________ CELL #_________________________________________ EMAIL__________________________________________ NAME_________________________________________ CELL #________________________________________ EMAIL____________________________________________ MEDICAL INFORMATION Please list any physical/psychological limitations, injuries, weaknesses or allergies that may affect the students participation: ________________________________________________________________________________________________________ ________________________________________________________________________________________________________ DOCTORS NAME________________________________ DOCTORS PHONE #___________________________________ EMERGENCY CONTACT 1 EMERGENCY CONTACT 2 NAME________________________________________________ CELL #_________________________ RELATIONSHIP________ NAME_______________________________________________ CELL #_______________________ RELATIONSHIP_________ THIS IS A LEGAL AND BINDING DOCUMENT. IF YOU DO NOT UNDERSTAND THIS DOCUMENT, YOU SHOULD SEEK THE ADVICE OF A LAWYER OF YOUR CHOICE. I, the parent or legal guardian of the above named student hereafter referred to as “student” do hereby permit the “student” to participate in gymnastics, tumbling, cheerleading, trampoline, or any other physical activities at The Cheer Pitt, Inc. here after referred to as “TCP”. By granting permission for “student” to participate in programs at “TCP”, I assume full responsibility for “student’s” personal safety and release “TCP”, its supervisors and employees from any and all liabilities that may arise due to any injury including death to “student” by reason of “student’s” participation in any activity at “TCP” or in which “TCP” is participating elsewhere. I understand there is personal risk involved in any activity that involves motion, height or rotation and that these risks could result in injuries which include but are not limited to, physical or emotional injury, paralysis, death, or damage to participants, to property, or to third parties. I declare “student” has been seen by a physician and is cleared to participate in physical activities such as gymnastics, cheerleading, trampoline and tumbling. In the event of an emergency, I would like the above mentioned “student” to be taken to a hospital or appropriate medical emergency clinic or medical office for medical treatment and I hold The Cheer Pitt, Inc., and its representatives harmless in their execution of this action. Additionally, I hereby agree to individually assume all financial responsibility for injuries, damages or property damages associated with the risks of the child’s participation at The Cheer Pitt, Inc. I assume financial responsibility for: (1) any injury to my child including medical costs and expenses incurred for treatment of the child resulting from the child’s participation in the activities of The Cheer Pitt, Inc., and I assume financial responsibility for: (2) damage to property and injuries to others incurred by, caused by or resulting from the child’s participation in the activities of The Cheer Pitt, Inc. . I authorize “TCP” to use photographs, video and/or other likenesses of “student” for use in “TCP” promotional materials or sales and waive any rights of compensation or ownership thereto. STUDENT NAME (PRINT)________________________________________________________ DATE:_________________________ STUDENT SIGNATURE (If 18 years or older)_______________________________________________________________________ PARENT/GUARDIAN NAME (PRINT)______________________________________________________________________________ PARENT/GUARDIAN SIGNATURE________________________________________________________________________________
Posted on: Fri, 16 Aug 2013 01:57:49 +0000
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