Northern Extreme Athletics Member Information & Release From Risk & Liability Waiver

Northern Extreme Athletics - 4307 Stewart Avenue Wausau WI 54401
Northern Extreme Athletics Member Information & Release From Risk & Liability Waiver

This Form Must Be Signed & Submitted Before An Athlete Can Participate In Any Activities at Northern Extreme Athletics.
Parent #1 Full Name (if over 18, please put your name as both parent and athlete name) *

First NameLast Name
Parent #2 Full Name

First NameLast Name
Athlete #1 Full Name*

First NameLast Name
Athlete #1 Date Of Birth*

MonthDayYear
Date
Athlete #2 Full Name

First NameLast Name
Athlete #2 Date Of Birth

MonthDayYear
Date
Athlete #3 Full Name

First NameLast Name
Athlete #3 Date Of Birth

MonthDayYear
Date
Athlete #4 Full Name

First NameLast Name
Athlete #4 Date Of Birth

MonthDayYear
Date
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail #1*
Home Phone Number

Area CodePhone Number
Cellphone Phone Number*

Area CodePhone Number
Emergency Contact #1*

First NameLast Name
Emergency Contact #1 Phone Number*

Area CodePhone Number
Emergency Contact #2

First NameLast Name
Emergency Contact #2 Phone Number

Area CodePhone Number
Please List Any Medical Conditions. If more than one athlete, please be sure to specify the athlete by name. If none, please specify none*
Please List Any Allergies. If more than one athlete, please be sure to specify the athlete by name. If none, please specify none*
Please List Any Medications Your Athlete Is Taking. If more than one athlete, please be sure to specify the athlete by name. If none, please specify none*
Name Of Physician*

First NameLast Name
Physician Phone Number*

Area CodePhone Number
Name Of Insurance Provider - Please Include Group / Policy Number*
Please List Any Other Important Information You Feel Is Pertinent
ASSUMPTION OF RISK/WAIVER OF LIABILITY - As legal guardian/ parent of of the above listed athletes, I recognize and understand that potentially severe physical injuries, including permanent paralysis, and/ or death can occur in sports and/ or activities involving height or motion, including but not limited to gymnastics, cheerleading, stunting, tumbling, trampoline, martial arts, dancing, birthday parties, open gym, squad training, camps, sleep-over and etc. Being fully aware of these dangers, I voluntarily consent to the aforementioned persons participating in any and all programs at Northern Extreme Athletics LLC and I ACCEPT ALL RISKS associated with that participation. In consideration for allowing my child to use these facilities, I, on my own behalf and the behalf of my child and our respective heirs, administrators, executors and successors hereby COVENANT NOT TO SUE and FOREVER RELEASE Northern Extreme Athletics LLC, its officers, directors, shareholders, employees or other representatives, whether paid or volunteer, from all liability for any and all damage, illnesseses or injuries suffered by my child while under the instruction, supervision, or control of Northern Extreme Athletics LLC, including without limitation, those damages or injuries resulting from acts of negligence on the part of its officers, directors, shareholders, employees or agents.I further agree to hold harmless and indemnify Northern Extreme Athletics LLC; including without limitation, all representatives, all staff personnel, and all administrators. I further release Northern Extreme Athletics LLC from any medical and/or legal costs which may arise due to any injury and/or illness sustained.PERMISSION FOR EMERGENCY MEDICAL TREATMENT/ MEDICAL INSURANCE I confirm that my child is in good health and that I have medical insurance on my child and will provide coverage while he/she is enrolled. I hereby authorize first aid by trained and/ or untrained staff members, employees, instructors, medical personnel and consent to any x-ray, exam, and medical or surgical diagnosis that is deemed necessary in case of emergency. Additionally, I hereby agree to individually provide for all possible future medical expenses which may be incurred by my child as a result of any injury sustained while participating at or for Northern Extreme Athletics LLC.I also give permission for photographs and videos of my child to be used in print or broadcast media as deemed appropriate for the promotion of any Northern Extreme Athletics activities.*

I accept the terms and conditions
Signature*

Clear
Date*

MonthDayYear
Date
Please Type Full Name Of Above Signature*

First NameLast Name
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