Skate Like a Girl General Liability Waiver

Are you an adult who has already been registered for a program on our ACTIVE registration site?

NoYes

Participant Information

Participant's Name*

First Name, Last Name

Camp/Program/Event Location

Participant's Birth Date*

MonthDayYear

Today

MonthDayYear

Age

Parent/Guardian Information

Name

First Name, Last Name

Phone*

Area CodePhone Number

E-mail*

Additional Email

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

Emergency Information

Emergency Contact's Name*

First NameLast Name

Relationship to Participant

Phone Number*

Area CodePhone Number

Alt. Phone Number

Area CodePhone Number

Medical History of Participant, Behavioral History, or anything else our staff should know about your child.

INFORMED CONSENT & ACKNOWLEDGEMENT:

In consideration of being allowed to participate in any way in the Skate Like a Girl clinic, program, related events, and activities the undersigned (or, if the participant is a minor, the person with the authority to consent on their behalf) acknowledges, appreciates, and agrees that:

1. The risk of injury from the activities involved in these programs is significant, including potential for permanent disability and death, and while particular rules, equipment, and personal discipline may reduce this risk, the risk of serious injury to myself and others does exist, and,

2. I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES or others, and assume full responsibility for my participation, and

3. I willingly agree to comply with the stated and customary terms and conditions for participation. If I observe any unusual significant concern in my readiness for participation and/or in the program itself, I will remove myself from participation and bring such to the attention of the nearest official immediately, and

4. For myself and on behalf of my/our heirs, assigns, personal representatives and next of kin HEREBY RELEASE Skate Like a Girl its officers, officials, agents, and/or employees, other participants, sanctioned events, sanctioned organizations, volunteers, sponsoring agencies, sponsors, advertisers, and if applicable, owners, leasors of premises used to conduct the event (Releasees), WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH, or loss or damage to person or property incident to my involvement or participation in these programs, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE, to the fullest extent permitted by law.

5. I, for myself and on behalf of my/our heirs, assigns, personal representatives and next of kin, HEREBY INDEMNIFY AND HOLD HARMLESS all of the above Releasees from any and all liabilities incident to my involvement or participation in these programs, EVEN IF ARISING FROM THEIR NEGLIGENCE, to the fullest extent of the law.

I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT INDUCEMENT. I ATTEST THAT I AM PHYSICALLY FIT AND HAVE BEEN TRAINED FOR THIS ACTIVITY.

I assume all risks, and hazards incidental to participating in the activity and do hereby waive, release, absolve, indemnify, and agree to hold harmless Skate Like a Girl, their supervisor, participants and instructors for any claim arising out of any injury to myself or the participant.

MEDICAL CONSENT & ACKNOWLEDGEMENT

I hereby authorize and give permission, that myself/the participant may be given emergency treatment including first aid and CPR by qualified Skate Like a Girl staff and volunteers. I also give permission for myself/the participant to be transported by ambulance and to be treated by any physician, hospital, health care provider, or other medical personnel selected by the staff of Skate Like a Girl to provide prompt medical services. I agree that once the participant is in the care of medical personnel or a medical facility, Skate Like a Girl shall have no further responsibility for the participant and I agree to pay all costs associated with such medical care and transportation.

In the event that I cannot be contacted, I further authorize consent to the medical, surgical, and hospital care treatment procedures to be performed for myself/the participant by a any physician, hospital, health care provider, or other medical personnel selected by a Skate Like a Girl staff when deemed necessary or advisable by the medical personnel to safeguard the participant’s health. I wave my right of informed consent to such treatment.

The health history provided to Skate Like a Girl is correct and not falsified to the best of our knowledge.

MEDIA RELEASE

I grant full permission to use any photographs, videotapes, motion pictures, recordings, or any other record of myself (or the participant) in this program for promotion of Skate Like a Girl.

If I do not want to grant these media permissions, I will notify staff onsite upon check-in.

Please email your local chapter if you have any questions:

Signature*

Demographic Information

As a non-profit organization, most funding comes from grants, and most grants require demographic information. If you feel comfortable, please share the below demographic information for the participant in the program to help us keep our programming going!

Pronouns

She/HerHe/HimThey/ThemOther

Pronouns

She/HerHe/HimThey/ThemOther

I have participated in a Skate Like a Girl program before

YesNo

I think of myself as (check the one that fits best)

Type a question

GENERAL LIABILITY WAIVER