Illinois Recreational Cheerleading Association 2015 SPRING
Transcription
Illinois Recreational Cheerleading Association 2015 SPRING
DO NOT TAPE OR STAPLE TOGETHER 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 DO NOT TAPE OR STAPLE TOGETHER 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 DO NOT TAPE OR STAPLE TOGETHER DO NOT TAPE OR STAPLE TOGETHER 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 DO NOT TAPE OR STAPLE TOGETHER