GENERAL PARTICIPATION WAIVER
This form is required for any person participating in an event(s) at IMPACT Elite LLC, such as: TRYOUTS, RECREATION CHEER, OPEN GYMS, CLASSES, CLINICS, PRIVATE EVENTS, ETC. This MUST be filled out by parent or legal guardian. One form is required per athlete/participant. You need to only submit one form, one time - unless any of your information changes.
ATHLETE / PARTICIPANT NAME
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First Name
Last Name
ATHLETE / PARTICIPANT BIRTHDATE
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-
Month
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Day
Year
Date
PARENT / LEGAL GUARDIAN NAME (if participant is under 18)
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First Name
Last Name
PARENT / LEGAL GUARDIAN PHONE NUMBER
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Please enter a valid phone number.
Format: (000) 000-0000.
PARENT / LEGAL GUARDIAN E-MAIL ADDRESS
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example@example.com
PARENT / LEGAL GUARDIAN HOME ADDRESS
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Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
ANY ATHLETE/PARTICIPANT MEDICAL CONDITIONS OR ALLERGIES
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EMERGENCY CONTACT
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First Name
Last Name
EMERGENCY CONTACT PHONE
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Please enter a valid phone number.
Format: (000) 000-0000.
ASSUMPTION OF RISK I the undersigned (if applicant/participant is 18 years of age or older) or parent/guardian of above listed minor applicant/participant acknowledge and fully understand that each applicant/participant will be engaging in activities that involve risk of serious injury, including permanent disability or death, and severe social and economic losses which might result not only from their own actions, inactions or negligence, but action, inaction or negligence of others, or the condition of the premises or of any equipment used and further, that there may be other unknown risks not reasonably foreseeable at this time, assume all the foregoing risk and accept personal responsibility for the damages following such injury, permanent disability or death. I hereby release, discharge, covenants to indemnify and not to sue IMPACT ELITE LLC, its affiliated organizations and sponsors, their coaches, and associated personnel, officers, directors, board members, including the owners and leasers of premises used to conduct the event, all of which are hereinafter referred to as ‘releasees’, from any and all liability to each of the undersigned, his/her heirs or next of kin for any and all against any claim by or on behalf of the applicant as a result of the applicant’s participation in an IMPACT ELITE LLC event.
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I have read the above and agree
COVID-19 RISK ACCEPTANCE By entering the facility, you are aware that you agree to fully accept all known and unknown risk, including the potential risk of exposure to respiratory illnesses such as COVID-19. COVID-19 is primarily transmitted via exhaled respiratory droplets, most often through coughing and sneezing. These droplets can travel up to six feet and are more commonly transmitted between persons rather than from equipment to persons. Although we regularly disinfect our equipment and presently are using enhanced cleaning methods plus enforce social distancing in our facility, you understand that you may be exposed to COVID-19 or its symptoms through no fault of our own. Known COVID-19 symptoms include fever, cough, shortness of breath or difficulty breathing, muscle pain, sore throat, new loss of taste or smell. More severe cases can lead to pneumonia, kidney failure, stroke, or even death. You understand and agree that you will hold us harmless and you will not hold us liable for any real or perceived symptoms of COVID-19 or any other disease, illness, or condition, nor for exacerbating any symptoms. You are fully aware and agree to accept all risks of entering the facility, using the equipment, working with coaches and instructors, attending classes, and/or interacting or being exposed to other members.
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I have read the above and agree
CONSENT FOR TREATMENT I hereby give my consent to have an athletic trainer, coach and/or doctor of medicine or dentistry or associated personnel to provide the athlete/participant with medical assistance and/or treatment and agree to be financially responsible for the cost of such assistance and/or treatment. I accept that all parties herein referred to above as releasees are not to be held responsible for any pre-existing medical conditions or any medical conditions I fail to disclose on my health history. I also agree to save and hold harmless and indemnify above releasees from all liability, loss, cost, claim or damage whatsoever, including death or damage to property, which may be imposed upon said releasee because of any defect in or lack of such capacity to so act or caused or alleged to be caused in whole or in part by the negligence of the releasee.
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I have read the above and agree
PHOTOGRAPHIC RELEASE Occasionally IMPACT Elite LLC uses photos or video of its students in print ads, on its website, its social media pages, or other marketing mediums. I understand that my child's likeness may be used in such advertising. These images will be used for IMPACT Elite LLC purposes only and will not be given or sold to outside companies or individuals.
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I have read the above and agree
OVERALL CONSENT I have read the above waiver/release and understand that (I) we have given up substantial rights by signing this release and sign below voluntarily. I the undersigned (if applicant/participant is 18 years of age or older) or parent/guardian of listed minor applicant/ participant, acknowledge and agree that I am the parent or legal guardian of the above named minor and therefore have the authority to grant these permissions. This authorization expires one year from the date it is signed.
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I have read the above and agree
Signature
Submit
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