Illinois Recreational Cheerleading Association 2015 SPRING

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Illinois Recreational Cheerleading Association
2015 SPRING SEASON Waiver Form
MEDICAL RELEASE FORM
(Completed for each participant PRIOR TO COMPETING)
ORGANIZATION NAME:
GRADE LEVEL OF
ATHLETE (circle please):
K/1
2
3
4
5
6
7
8
H.S.
PARTICIPANT INFORMATION:
PARTICIPANT NAME:
HOME PHONE:
BIRTH DATE:
MAILING ADDRESS:
CITY:
STATE:
ZIP:
E-MAIL ADDRESS:
EMERGENCY CONTACT:
PHONE NUMBER:
This Release of Medical and Personal Information and Statement of Waiver shall apply to all of the following
Events for the 2015 season:
Date
Event
03/08/15 Spring Ahead 03/14/15 Cheer Madness 04/19/15 Cheer Drama 04/26/15 Top Dawg Location
Conant High School
Hoffman Estates, Illinois Hampshire High School
Hampshire, Illinois Lincoln Way North High School, Frankfort, Illinois Hampshire High School
Hampshire, Illinois DO NOT TAPE OR STAPLE TOGETHER
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Illinois Recreational Cheerleading Association
2015 Waiver Form
Page Two
Release of Medical and Personal Information and Statement of Waiver
I, a parent or legal guardian of minor, authorize the Illinois Recreational Cheerleading Association (IRCA) & American
Recreational Cheerleading, Inc. to copy and distribute this document in any format they so choose, including but not
limited to, paper, electronic and/or facsimile transmission to all events for the 2015 season as listed on page one of this
document.. I fully understand that this document will be used as the “sole waiver” for those events. My signature on this
document represents that I agree to the release of my minor’s personal and health information along with my personal
information and I waive my rights to any and all actions against the Illinois Recreational Cheerleading Association
(IRCA), American Recreational Cheerleading, Inc. and Redlok Productions, Inc. for losses or damages which may be
suffered by the minor or the undersigned in connection with such release including any injury, loss or damage arising by
reason of the negligence, or alleged negligence, including willful and wanton negligence, of the Illinois Recreational
Cheerleading Association (IRCA), American Recreational Cheerleading, Inc. and Redlok Productions, Inc.
I, the parent or legal guardian of the below named minor, do hereby give my consent to his/her participation in all
activities of the Illinois Recreational Cheerleading Association (IRCA), American Recreational Cheerleading, Inc. and
Redlok Productions, Inc. as outlined in this document. In case of any illness or injury to my minor resulting from
participation, I hereby waive any and all claims against the organization, sponsors, supervisors, managers, owners or
Board Members and hereby release, discharge, hold harmless and indemnify the Illinois Recreational Cheerleading
Association (IRCA), American Recreational Cheerleading, Inc. and Redlok Productions, Inc. for any and all claims,
demands, damages or rights of action against them and agree not to sue the Illinois Recreational Cheerleading
Association (IRCA), American Recreational Cheerleading, Inc. and Redlok Productions, Inc. or any of its officers or
employees for any injury, loss or damage which may be suffered by the undersigned or minor of the undersigned in
connection with such activities, including any injury, loss or damage arising by reason of the negligence, or alleged
negligence, including willful and wanton negligence, of the Illinois Recreational Cheerleading Association (IRCA),
American Recreational Cheerleading, Inc. and Redlok Productions, Inc. or any such official or employee(s) of the
Illinois Recreational Cheerleading Association (IRCA), American Recreational Cheerleading, Inc. and Redlok
Productions, Inc. In the event of an emergency situation relating to my minor listed below, and in the event that I am
unavailable, I hereby give consent to allow Emergency Medical Technician, Athletic Trainers or any medical institution
to administer whatever such emergency medical care is deemed appropriate by the emergency medical staff until I can
be contacted.
I, the undersigned, give my consent for photographs or videos to be taken of myself or my minor at any activities of the
Illinois Recreational Cheerleading Association (IRCA), American Recreational Cheerleading, Inc. and Redlok
Productions, Inc., for publication in promotional or marketing material, web site, or any other uses the Illinois
Recreational Cheerleading Association (IRCA), American Recreational Cheerleading, Inc. and Redlok Productions, Inc.
deem necessary. I further agree that I consent to the use of said photographs or video without right to compensation of
any type or form, that I do not expect any monetary payment or any other consideration, and that I do not have any right
to any monetary payment or any other consideration. I, the undersigned, also agree that my personal information may be
used for communications, including but not limited to, information regarding competitions and events, marketing and/or
promotional materials, from the Illinois Recreational Cheerleading Association (IRCA), American Recreational
Cheerleading, Inc. and Redlok Productions, Inc. and/or their affiliates. I also understand that I may opt out of such
communications at any time by contacting the Illinois Recreational Cheerleading Association (IRCA).
By signing below, I, a parent or legal guardian of the below named minor, hereby indicate that I have read this
document and agree to any and all such terms contained herein.
CHEERLEADER NAME: _____________________________________
ORGANIZATION NAME: _______________________________________
_________________________________ ________________________________
(Please Print) Parent or Legal Guardian Name
Signature of Parent or Legal Guardian
_________________________________
Date
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Athletico Waiver of Liability
I, parent or legal guardian of below named child, consent to have an Athletico, Ltd. athletic trainer or
associate personnel provide my child with first-aid assistance and/or treatment and agree to save and hold
harmless, indemnify and release Athletico, its officers, agents and employees, including Athletico’s athletic
trainer, from and against any and all liability, suits, loss, cost and expenses including but not limited to
reasonable attorney’s fees and court costs, claims of damage whatsoever, including death or damage to
property caused by or as a result of any act or omission of Athletico, its staff, and any other of its agents or
employees.
CHEERLEADER NAME: ___________________________________
Parent Name (Please Print)
Parent Signature
Date
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