Medical Release Form - 2015-2016 printable pdf download

MEDICAL RELEASE FORM

2015-2016

This medical release form is applicable for all Texas Cheerleader

OPEN State Championship

Events (East, North, South and the Valley in Texas), Texas Cheerleader All-Star Nationals, and all

™

FUN Cheer

Competition events (All-Star Athletics™, All-Access Championship

, Spook Night

™

Championship

, Winter Wonderland

, Christmas Spectacular, All-Star Regional, Sweetheart and

™

Spirit Splash Classic, 1-Day and 2 Day National Championships, Fun Dance

and Cheer World

™

All-Access Championships

Parents complete only ONE and coaches make copies for each event the competitor will be

attending.

Please include a TEAM ROSTER with medical release forms at each event.

Participant Name: __________________________________________________________

Gym/School Representing: ___________________________________________________

Address: __________________________________________________________________

City: _____________________________ State: ____________ Zip: __________________

Birth date: ________________________ Age:_________________ Grade: _____________

Parent or Guardian Name: ____________________________________________________

Parent or Guardian Phone Number: _____________________________________________

Secondary Contact: _________________________________________________________

Phone Number: ____________________________________________________________

Email Address: ____________________________________________________________

Please list any medical conditions that we should be aware of: _______________________

_________________________________________________________________________

Allergies to Medicines: ______________________________________________________

As in all athletic activities, there is an inherent risk to injury. I do hereby on behalf of myself and my

child, release and forever discharge the event hosting organization, hosting facility, its principals,

partners, members, managers, employees, officers, contractors, consultants, advisors, volunteers and

agents from all claims, demands, and causes of action for injury to persons or property arising from

participating in the event. I also understand that first aid will be rendered and/or if necessary or

instructed to do so, give my permission to take my child to such a place as may be necessary for proper

care and treatment. I grant permission to any hospital or clinic staff member to administer immediate

treatment if necessary.

By granting permission for my child to participate in on of the above mentioned events, I assume full

responsibility for said participants’ personal safety and release the above mentioned hosts from any and

all liabilities that may occur from injury, including death to said participant that may arise from

participating in this event. I understand that these activities can result in serious injury and disability. I

assume all responsibility and waive any claim for compensation for accidental injury, disability or death

while attending the event and hereby hold harmless the host company, staff and hosting facility.

I have read and understand this document and agree that my child will follow the rules that pertain to

the event. I further attest that and acknowledge that my child is in good physical health and is

physically able to participate.

I understand that my child may be photographed, filmed video and/or audio taped during this event. I

give permission for video and/or photographs of my child or myself to be used for promotional

purposes for these events.

Parent/Guardian Signature: X___________________________________ Date: ___________________

Physicians Name: ___________________________________ Phone Number: ___________________

Insurance Co.:____________________________ Policy Number: _____________________________

Medical Release Form - 2015-2016

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