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Medical Release form CheernasticsPosted Thursday, January 22, 2009 by April Smith War Eagle Cheernastics Participation &
MEDICAL RELEASE FORM
(Please Print CLEARLY!!!)
___________________________________ __________________________________
Participant’s Name Age Home phone #
__________________________________
Parent/Guardian’s Phone # Grade/Teachers Name
Name of Parent or Guardian Emergency Contact Phone #
Participant’s Address City Zip Code
__________________________________________
Medical Insurance Company
Medical Insurance Policy #
__________________________________________________
Parent or Guardian’s Address if different from Parrticipant
Parent Email Address
__________________ ________ _________
City State Zip Code
List any medication to which participant is allergic, any previous medical conditions which could impair his/her performance, and any medication currently being taken.
_______________________________________________________________________
I. I, the undersigned parent or guardian, do hereby grant permission for my daughter/son, whose name is _________________________________, and hereinafter shall be referred to as “participant,” to participate in the War Eagle Cheernastics classes. In order that the participant may receive the necessary medical treatment in the event of an injury or illness, I hereby hold the Coaches/ Instructors and its representatives harmless in the exercise of this authority.______________ (Please initial).
II. I further acknowledge and understand and agree that in taking part in this class there is a possibility of physical illness or injury (minimal, serious, or catastrophic) and that participant is assuming the risk of such injury by participating.______________ (Please initial).
III. I further agree to hold harmless Putnam County Schools., including its, gymnastic instructors, coaches, and staff, the administrators of the classes, and the facility in which the classes are being conducted for any injury or illness incurred by participant prior too, during the course of the classes, and after.______________ (Please initial).
Appearance Clause:
Permission is granted to use my daughter’s/son’s picture or image in future advertisements or literature for the PCHS War Eagle Cheernastics program.
I have read and agree to the above release and appearance clause.
____________________________________ ____________________________________
Date
Signature of Parent or Guardian  |
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