MEMBER REGISTRATION

*This page is exclusively for Faulkner Fundamental's initial program registration and liability agreement. Please ensure you complete and sign this form to enroll your child in any current or future Faulkner Fundamental activities. For payment and individual event registration, you must proceed to the Faulkner Fundamental website at www.faulknerfundamentals.com. For any questions please contact LaKisha Faulkner at 901.568.7088.

Athlete's Name*

First NameLast Name

Grade*

Age*

Birthdate*

Date

Gender

What other subjects has your child shown interest in? i.e. other sports, art, music, math, writing, etc.

Is the athlete prescribed to an inhaler?*

YesNo

Does the athlete have any known allergies?*

YesNo

Does the athlete need an EpiPen near?*

YesNo

Has your child previously had any broken/fractured bones and/or sprained ligaments?*

YesNo

If you answered yes to any of the medical questions above, please provide details and/or instructions.

Please list any medical or physical conditions that your child has that could prevent he/she from participating in any activities?

Do you have medical insurance for your child?*

YesNo

Please list medical insurance provider:

Parent/Guardian's Name*

First NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Primary Phone *

Please enter a valid phone number.

Alternate Phone

Please enter a valid phone number.

Is your primary phone a home or cell number?

HomeCell

Email*

example@example.com

Emergency Contact*

First NameLast Name

Emergency Contact Phone*

Please enter a valid phone number.

Relationship to Parent/Guardian

I, First Name* Last Name* , hereby acknowledge that I am voluntarily allowing my child, First Name* Last Name* , to participate in all events and activities organized by Faulkner Fundamentals.

In consideration for being permitted to participate in any of the
youth sports activities, I hereby agree to release, indemnify, and hold harmless
Faulkner Fundamentals, its officers, directors, employees, agents,
representatives, volunteers, and assigns, including Morning View Baptist Church and all of it's assessors from any and all claims, demands,
actions, or causes of action of any kind whatsoever arising out of or related
to any loss, damage, or injury, including death, that may be sustained by my
child, whether caused by the negligence of Faulkner Fundamentals, its
officers, directors, employees, agents, representatives, volunteers, or
otherwise, while participating in the youth sports events and activities.

I understand and acknowledge that my child is physically fit to
participate in the sports activities and has no medical conditions that would
prevent safe participation. I further understand and acknowledge that participating
in sports activities involves inherent risks, including but not limited to the
risk of physical injury such as falls, collisions, equipment related-accidents or
death; I voluntarily assume all such risks including giving up my right to sue. I authorize the organizers, coaches, volunteers or the facility of Morning View Baptist Church to seek medical attention for my child in case of an emergency.

I acknowledge that I have been advised to obtain personal health
insurance coverage prior to my child's participation in the youth sports events and activities, and I agree that any medical expenses incurred as a result of any injury my child sustain during activities will be my sole responsibility.

I hereby grant permission to Faulkner Fundamentals to take
and use photographs, videos, or other images of myself and/or my child for
promotional or educational purposes related to Faulkner Fundamentals' involvement.

I have read this liability waiver, and I fully understand its terms. I voluntarily agree to its terms and conditions, and I understand that by signing this waiver, I am giving up substantial legal rights, including the right to sue Faulkner Fundamentals and/or Morning View Baptist Church. By signing this document using the electronic signature, I understand that it carries the same legal weight as a handwritten signature. *

Signature*

Date*

Date

FAULKNER FUNDAMENTALS

Athlete's Information:

Athlete's Medical History

Parent/Guardian's Information:

Liability Waiver