Medical Consent and Indemnity Form

Please complete Medical Consent and Indemnity form before ding training of any kind with Vulcana Circus. By signing this form I understand I have agreed to all terms and conditions, and I understand that it is my full responsibility to notify Vulcana should any of my information change.

Full Name*

First NameLast Name

Phone Number*

Area CodePhone Number

Date of Birth*

DayMonthYear

Emergency Contact name*

First NameLast Name

Emergency Contact number*

I,*

Name

(Parent/Guardian – if under 18 years of age) hereby give permission for the Team Manager, or designated representative, to seek medical aid in the event of an accident, injury or illness. General medical aid, including transport, will be at the discretion of the Manager or designated representative.

(General Note: Parents/Guardians will be contacted, if possible, prior to any medical attention being given.)

Do you have medical conditions that may affect you during your time with us? Eg: Injuries, epilepsy, asthma etc

YesNo

If yes please give more info

Are you currently pregnant, or have you been pregnant in the last 12 months?*

YesNo

Do you Have any access requirements? (ie - interpreter, cultural requirements, physical access requirements)*

YesNo

If yes, please give more detail:

I the participant declare and agree that I am participating in this activity of my own free will and entirely at my own risk. I do so in full knowledge of the risks associated with the particular activities I am participating in. These risks include but are not limited to; the risk that I may suffer harm, personal injury, or loss of life as a result of an accident, including falling from from a height or apparatus. I am aware that I will be participating in these activities along with other participants and sharing the practice space with others during the activities, and undertake to observe caution, particularly when another participant is nearby. I warrant that I am in a fit state of health and physically capable of participating in the circus activities and that I have completed the ‘Participant Medical Information Form’ attached to the best of my knowledge. I agree to follow any safety guidelines, directions, instructions or warnings given by Vulcana Women’s Circus’ (“Vulcana”) employees, trainers, instructors, volunteers or associated persons. I agree that I will exercise reasonable care for my own safety when participating in the above circus activities. I waive any and all claims or legal actions, including personal injury, negligence or other claims I may have at any time against Vulcana or any of its employees, trainers, guest trainers, trainees or volunteers when acting on behalf of Vulcana, in respect of any liability, loss or costs arising or that may arise at any time, directly or indirectly, from my participation in Vulcana training classes, rehearsals or performances. I also agree to indemnify Vulcana and its employees, trainers, guest trainers, trainees or volunteers for any liability, loss or costs that they may incur at any time arising or that may arise, directly or indirectly, from any negligent act or omission on my part, including, but not limited to, my failure to abide by any safety guidelines, directions, instructions or warnings given by Vulcana and its employees, trainers, guest trainers, trainees or volunteers.

I agree

I Agree*

I have read, understood, acknowledge and confirm that the information is true and correct

Full Name*

First NameLast Name

Medical Consent & Indemnity

Medical and access info

Consent to participate in activities