JMU Athlete Waiver

JMU Athlete Waiver
Name*

First NameLast Name
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Phone Number*
Please enter a valid phone number.
Date of Birth*

MonthDayYear
Date
Name of Parent/Legal Guardian*

First NameLast Name
Emergency Contact*

First NameLast Name
Emergency Contact Phone Number*
Please enter a valid phone number.
List all allergies:*
List any medical conditions:*
List all medications currently taking: *
Health Insurance - ID# - Subscriber Name - Subscriber Date of Birth*
Relationship to Insured:*

SelfChild/Dependent
Primary Care MD: Name and Phone Number*
CERIFICATION OF PHYSICAL FITNESS TO PARTICIPATE:
1. I understand that a risk of participating in any sport, including the Athletic Development Program, is the risk of injury, including but not limited to serious permanent injury, paralysis, and death. To minimize the risk of injury, the athlete agrees to obey all safety rules and to report fully any problems related to his/her physical condition to the summer camp coaches or assistants as soon as the problem arises.
2. By signing the registration form, I certify the following:
a. That the participating athlete is not currently under the care of a physician for an injury or illness that would prevent his/her safe participation in the Athletic Development Program.
b. That the athlete is not currently being treated for or recovering from an orthopedic injury what would prevent his/her safe participation in the Athletic Development Program.
c. That the participating athlete has no history of fainting or other problems related to strenuous exercises.
d. That the athlete is in good health and there is no reason he/she cannot safely participate in strenuous physical activity.
Athlete Signature*

Clear
Date*

MonthDayYear
Date
Parent/Guardian Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty: