Student Information and Liability Form

Student Information Form
Student 1 Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Student 2 Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Parent/guardian name

First NameLast Name
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Please enter a valid phone number.
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
Please list any known allergies or sicknesses, diseases or ailments of participant
In case of any of the above listed sicknesses, student has been given medical clearance to conduct inline skating activity

YesNoN/A
I authorize Skatesational to use photographs of student taken during class/lessons for website and social media. Please include on their name label in class "NO PHOTO" so that I know they should not be photographed.

YesNo
Signature

Clear

Release of Liability
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.
Date

MonthDayYear
Date
Printed Name

First NameLast Name
Signature

Clear
Child's name and DOB
Child's Name and DOB
Signature

Clear

Should be Empty:

Student Information Form

Release of Liability