Insurance provider Insurance number blanks Primary care physician name phone number Emergency contact 1 First Name Last Name Phone Number Emergency contact 2 First Name Last Name Phone Number I allow emergency contact to pick up my son/daughter Yes No Other adults authorized to pickup First Name Last Name
AMATEUR ATHLETIC WAIVER AND RELEASE OF LIABILITY. READ BEFORE SIGNING
Name of organization/Instructor: Skatesational / Priscilla Barton
2020 WAIVER, All participants must sign
In consideration of being allowed to participate in any way in the inline and roller skating athletic/sports program, related events and activities, the undersigned acknowledge, appreciate and agree that:
1. The risk of injury from the activities involved in this program is significant, including the potential for permanent paralysis and death. And while particular rules, equipment and personal discipline may reduce this risk, the risk of serious injury does exist; and, 2. I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASESES 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 however, I observe any unusual significant hazard during my presence or participation, I will remove myself from participation and bring such attention of the nearest official immediately; and, 4. I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE AND HOLD HARMLESS Skatesational, Priscilla Barton their officers, officials, agents, and or employees, whether paid or not, other participants, sponsoring agencies, sponsors, advertisers and if applicable, owners and lessors 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. WHETHER
ARISING FROM NEGLIGENCE OF THE RELEASEEES OR OTHERWISE.
5. I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHT BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT INDUCEMENT.
For participant of minority age (under age 18 at time of registration)
This is to certify that I, as parent/guardian with legal responsibility for this participant, do consent and agree to his/her release as provided above of all Releasees, and, for myself, my heirs, assigns, and next of kin, I release and agree to indemnify and hold harmless the Releasees from any and all liabilities incident to my minor child's involvement or participation in these programs as provided above, EVEN IF ARISING FROM THE NEGLIGENCE
OF THE RELEASEES, to the fullest extent permitted by law.