MEDICAL and PARENTAL CONSENT

 MEDICAL AND PARENTAL CONSENT & WAIVER OF LIABILTY
RE: Cheerleading and Kickline Game Team Season 2015
Participant’s Name: ___________________________________________________________
Date of Birth: _________________________ Age: ___________ Grade (9/15): ___________
Address/City/State:______________________________________________________________
Parent/Guardian Name (1):________________________________________________________
Parent/Guardian Name (2):________________________________________________________
Address (1): ____________________________________________________________________
Address (2):____________________________________________________________________
Cell Phone (1):__________________________ Cell Phone (2):___________________________
E-mail (1): _____________________________ E-mail (2):______________________________
Emergency Contact if Parent/Guardian cannot be reached: In the event that I/we
cannot be reached, I/We authorize the following person(s) to act on my behalf for the care and
transportation of my child and GCS has my permission to contact these people:
1.
Name
Address
Phome
Name
Address
Phone
2.
MEDICAL HISTORY (List Limitations):
Allergies/Other: ________________________________________________________________
Current Medications/Other:_______________________________________________________
Participants Physician Name:_____________________________Phone#__________________
Garden City Spirit. • 108 Tullamore Road, Garden City, NY 11530
www.gcspirit.com • [email protected]
1 Parental Consent & Waiver of Liability
RE: Cheerleading and Kickline Game Team Season 2015
Child’s Name:___________________________________________________
Address: _______________________________________________________
Mother’s Name: __________________________________________________
Father’s Name:___________________________________________________
PLEASE READ THIS PARENTAL CONSENT AND WAIVER OF LIABILITY
CAREFULLY
AND
ACKNOWLEDGE
YOUR
AGREEMENT
AND
UNDERSTANDING BY SIGNING BELOW
NOTICE TO ALL PARTICIPANTS: Each game team participant must present a
completed form. If the participant is under the age of eighteen (18) years, the form must
be completed by the parent or legal guardian of the participant. Any participant who does
not present the form for the activity will not be permitted to participate. Please be
advised that you are participating in the above-referenced activity (“Activity”) at your
own risk.
A. Permission to Participate and for Medical Treatment:
I/We, the undersigned, hereby give permission for our child, named above, to participate
in cheerleading and/or kickline dance activities in the Garden City Enterprises, LLC
DBA Garden City Spirit (GCS) Cheerleading and Kickline/Dance Game Team Program
for the 2015 Game Team Season. I/We agree to abide by all the rules and regulations set
forth by GCS. I/We do hereby certify that our child is in good health, has been to a
physician within the last year and is physically able to participate in the activity with
GCS. I/We understand that the insurance, which is carried by GCS, is secondary to
whatever coverage we have. In the event of a claim, I/we agree to submit the claim to our
insurance company. If no insurance coverage exists, the insurance coverage provided
through GCS becomes the primary coverage.
In the event of an injury, I/we hereby give permission for our child, named above, to be
transported to a nearby emergency medical facility. Additionally, I/we give permission
for medical treatment to be administered as deemed necessary by the medical staff.
Garden City Spirit. • 108 Tullamore Road, Garden City, NY 11530
www.gcspirit.com • [email protected]
2 B. Waiver of Liability:
I/We acknowledge that I am/we are fully aware of the potential dangers of participation
in any sport and I fully understand that participation in cheerleading and/or kickline
dance may result in SERIOUS INJURIES, PARALYSIS, and PERMANENT
DISABILITY AND/OR DEATH. Furthermore, I/we do hereby waive, release, absolve,
indemnify, and agree to hold harmless Garden City Enterprises, LLC DBA Garden City
Spirit and their owners, administrators, board members, coaches, agents, volunteers, and
any and all organizers, sponsors, supervisors, participants, and persons transporting the
above named participant to and from activities, from any claim arising out of any injury
to my/our child WHETHER THE RESULT OF NEGLIGENCE OR FOR ANY OTHER
CAUSE.
I/We do hereby authorize Garden City Enterprises, LLC DBA Garden City Spirit to
utilize any and all photographs, pictures, videos or other likeness of our child or anyone
assigned guardianship of our child, as they deem appropriate in its promotional materials,
social media and/or teams films.
C. Injuries/Assumption of Risk:
I/We acknowledge that injuries may occur in the course of any athletic activity, and I/we
hereby specifically assume all risk of any injury occurring during the course of our
child’s participation in the Game Team Season.
I/We hereby warrant and acknowledge that I have been informed of any and all risks
involved with the activity. I/We are eighteen (18) years of age or older and competent to
contract in my/our own name in so far as the above is concerned or that if I/We am under
eighteen (18) years of age, my parent or legal guardian has reviewed and signed this
Notice, Acknowledgment and Release.
I/We have read the foregoing before affixing my signature below, and warrant that I/We
agree with and fully understand the contents thereof.
Date:________________________
___________________________________________________
Print Name - Participant over 18 or Parent/Legal Guardian
___________________________________________________
Sign Name - Participant over 18 or Parent/Legal Guardian
Important for 2015 HOLD THIS FORM – DO NOT MAIL
GCS Parental Consent must be submitted in Hard Copy on or before the first
practice on August 3rd.
Garden City Spirit. • 108 Tullamore Road, Garden City, NY 11530
www.gcspirit.com • [email protected]
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