Medical Release Form

ADVERTISEMENT

MEDICAL RELEASE FORM
I fully understand that ACE of Jackson (ACE) and staff are not physicians or medical practitioners of
any kind. With the above in mind, I hereby release the staff of ACE to render temporary first aid to my
child or children in the event of any injury or illness, and if deemed necessary by the staff of ACE, to
call a doctor and seek medical help, including transportation to any health care facility or hospital, or
the calling of an ambulance for said child should the staff of ACE deem it necessary.
We, the staff of ACE, recognize our obligation to make our clients and their parents aware of the risks
and hazards associated with the sport of cheerleading. Competitors may suffer injuries, possibly minor,
serious or catastrophic in nature. These activities can be dangerous and can lead to injury. It is the
parents who should make their children aware of the possibility of injury and encourage their children
to follow all the safety rules and coaches’ instructions.
The undersigned agree, ACE and its’ staff members are not responsible for injuries sustained by any
cheerleader during the course of tumbling, stunting, cheerleading, or dancing in which he/she may
participate or while traveling to or from the event. With the above in mind, and being fully aware of the
risks and possibility of injury involved, I consent to have my child or children participate in the
programs offered by ACE. I, my heirs, executors, and other representatives, waive and release all rights
and claims for damages that I or my child/children may have against ACE and or its’ representatives
whether paid or volunteer. I also affirm that I now have and will continue to provide hospitalization,
health and accident insurance coverage that I consider adequate for both my child’s protection and my
own protection.
APPEARANCE CLAUSE
Permission is granted to use my son/daughter’s picture or image in future advertisement and literature
for ACE of Jackson and events sponsored and conducted by them. I have read and agree to the above
release and appearance clause
X____________________________________________________
_________________________
Participants or Participants Parent/Guardian Signature if under (18)
Date
Participant Name
_________________________________________
Participant Address
___________________________________________
City, State, Zip Code
Home Phone
_____________________________________
___________________________________________
Parent/Guardian cell phone
Emergency contact name & phone
_____________________________________
___________________________________________
Medical Insurance Company
Policy and Group Number
_____________________________________
___________________________________________
Athlete Date of Birth_______________________________________________________________
E-mail address ____________________________________________________________________
Parent’s name (printed) ____________________________________________________________
____________
_________________________________________
Director’s Signature
Parent Initial

ADVERTISEMENT

00 votes

Related Articles

Related forms

Related Categories

Parent category: Legal
Go