Action Spirit Camp Participant

This year we have designed a summer camp where children can learn while having fun and develop their skills!

Name of the Child*

First NameLast Name

What is your Home Gym?

Name of the Parent/Guardian*

First NameLast Name

Child's Birthday

Date

Parent Email

example@example.com

Mother's Mobile Number

Mother's Work Number

Father's Mobile Number

Father's Work Number

Please list any current or previous accidents, illnesses or physical limitations that would stop or prevent your child from participating in Action Spirit LLC.’s programs - otherwise please state “NONE”.

Child/Parent/Guardian's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Allergies

Medications

Other Medical Conditions

Whom to Contact in Case of Emergency

Full NameRelationship

Emergency Contact Phone Number

Please enter a valid phone number.

Doctor Name

Full NamePhone

Insured Name

Full NamePolicy

Insurance Company

NamePhone #

Insurance Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Statement of Consent & Waiver

I give the above named permission to participate in the program(s) of Action Spirit, LLC. Also, the above named child (his/her legal guardian or parent if under eighteen years of age), agrees to indemnify and hold harmless Action Spirit, LLC, it’s officers, employees and coaches/instructors from and against all liability, claims, suits, damages, losses and expenses, including attorney fees, threatened or incurred, and arising from the child’s participation in any Action Spirit, LLC, program, or by reason of any injury or any damage to said child or to any person or property occurring during said participation, or from any cause whatsoever.

I fully realize that activities with Action Spirit, LLC and can be dangerous and could result in serious injury or possibly death and freely assume that risk. In the event of an emergency, I give permission for Action Spirit, LLC, and or, to give my child simple first aid and to arrange for transportation to a hospital and receive emergency medical treatment.

I will assume all costs for medical care. The above named child(ren) is physically able to participate in activities with out limitations (unless otherwise stated). It is the responsibility of the Parent/Guardian to let us know of any updates throughout the year.

I have read all the information contained within this waiver and by checking the box below, I accept the content contained within this waiver. I also, acknowledge that I am the legal guardian of the participant named above.

I accept

Date Signed

Date

Summer Camp Activity Waiver Form