Fitness & Recreation Registration Form

Participant's Information

Participant’s Name*

First NameLast Name

Birth Date*

MonthDayYear

Gender

MaleFemaleNonBinary

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Parent/Guardian Information

If you are under 18 your legal Guardian Must Fill this form out.

Name

First NameLast Name

Home Number

Cell Number

E-mail

example@example.com

Emergency Information

Emergency Contact's Name

First NameLast Name

Relationship

Phone Number

Alt. Phone Number

Does the participant have any allergies, chronic illness, or medical conditions? If yes, please describe.

Is the participant prescribed an inhaler? If yes, please explain any instructions.

I Am Registering for:*

Urban Survival FundamentalsUrban Survival Gladiator CampJiu JitsuFitness Training

Informed Consent and Acknowledgement I hereby give my approval for myself/my child’s participation in any and all activities prepared by United Community Empowerment during the selected activities. In exchange for the acceptance of said my/my child's candidacy by United Community Empowerment, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless United Community Empowerment and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected training, or recreation sessions. In case of injury to said myself/ my child, I hereby waive all claims against United Community Empowerment including all coaches and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in all sports activities, including fitness training and self defense. Some of these injuries include, but are not limited to, the risk of fractures, paralysis, or death.

Medical Release and Authorization As Parent and/or Guardian of the named participant, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed. Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named athlete. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me. Permission is also granted to United Community Empowerment and its affiliates including Directors, Coaches, and Team Parents to provide the needed emergency treatment prior to the child’s admission to the medical facility. This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child /myself.

Confirmation BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

Photo Waiver

During activities, we take photographs involving particpants to share the organizations positive vibe and updates. By which incidentally, some photographs may capture your child's participation, directly or indirectly.

These photos may be published through our website, social media pages, news bulletins, billboards, and ads.

With this, we seek for your consent in allowing us to publish photos which may involve your child to the said platforms.

By submitting this registration form you consent to the terms listed above. Thank you.

Signature

Clear

UCE Recreation Registration