EBF Summer Registration Form

THE EDWARD BROWN FOUNDATION

GLOVE UP - COOL DOWN SUMMER PROGRAM REGISTRATION
Which program are you registering for?*
Participant Information
Child's Name*

First NameLast Name
Birth Date*

MonthDayYear
Grade*
Gender*

MaleFemale
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Information
Name*

First NameLast Name
Phone Number*
Alt. Phone Number
Please enter a valid phone number.
E-mail*
example@example.com
Emergency Information
Emergency Contact's Name*

First NameLast Name
Relationship*
Phone Number*
Alt. Phone Number
Does the child have any allergies, chronic illness, or medical conditions? If yes, please describe.
Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities offered by the Edward Brown Foundation during the selected camp. I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless the Edward Brown Foundation and all its representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected program sessions.

In case of injury to said child, I hereby waive all claims against the Edward Brown Foundation, including all staff and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in all sports and recreational activities. Some of these injuries include, but are not limited to, the risk of fractures, paralysis, or death.
Medical Release and Authorization

As Parent and/or Guardian of the named participant, I hereby authorize the diagnosis, x-ray, and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency that requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

Permission is also granted to the Edward Brown Foundation and its affiliates including Directors and staff to provide the needed emergency treatment prior to the child’s admission to the medical facility.

Release authorized on the dates and/or duration of the registered program.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of the named minor child in my absence.
Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Signature*

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Date*

MonthDayYear
Date

Photo and Video Release
Dear Parent/Guardian:

During our programs, we take photographs and vidoes of activities involving participants to share the Edward Brown Foundation's mission and updates. By which incidentally, some photographs may capture your child's participation, directly or indirectly.

These photos may be published through our website, social media pages, and marketing materials.

With this, we seek for your consent in allowing us to publish photos which may involve your child to the said platforms.

Please do provide your response by selecting your choice below and submitting this form:
Photo Release Consent*

I hereby allow the reproduction and publication of my child's photograph(s)I do not allow the reproduction and publication of my child's photograph(s)
Name of Child*
Name of Parent*
Signature*

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Date*

MonthDayYear
Date

Waiver and Release of Liability

Brikhouse Boxing & Fitness
Date   Date*
{MemberName}    First Name*   Last Name*
Address    Street Address*      City*   State*   Zip*
{HomePhone}  Phone Number*
Waiver and Release of Liability

It is understood and agreed that THE MEMBER has his/her physician's permission to engage in physical exercise and/or tanning and that Brikhouse Boxing & Fitness does not make any warranties or representations with respect to the advisability/non-advisability of the THE MEMBER to engage in such exercise and/or tanning. THE MEMBER does hereby remise, release, and forever discharge Seller of and from all actions and causes of actions, suits, claims, and demands arising out of injuries sustained on Seller's promises.

Express assumption of risk: I, the undersigned, am aware that there are significant risks involved in all aspects of physical training. These risks include, but are not limited to: falls which can result in serious injury or death; injury or death due to negligence on the part of myself, my training partner, or other people around me; injury or death due to improper use or failure of equipment; strains and sprains. I am aware that any of these above mentioned risks may result in serious injury or death to myself and or my partner(s). I willingly assume full responsibility for the risks that I am exposing myself to and accept full responsibility for any injury or death that may result from participation in any activity or class while at, or under direction of Brikhouse Boxing & Fitness.

I acknowledge that I have no physical impairments, injuries, or illnesses that will endanger me or others.

Release: In consideration of the above mentioned risks and hazards and in consideration of the fact that I am willingly and voluntarily participating in the activities offered by Brikhouse Boxing & Fitness, I, the undersigned hereby release Brikhouse Boxing & Fitness, their principals, agents, employees, and volunteers from any and all liability, claims, demands, actions or rights of action, which are related to, arise out of, or are in any way connected with my participation in this activity, including those allegedly attributed to the negligent acts or omissions of the above mentioned parties. This agreement shall be binding upon me, my successors, representatives, heirs, executors, assigns, or transferees. If any portion of this agreement is held invalid, I agree that the remainder of the agreement shall remain in full legal force and effect.

If I am signing on behalf of a minor child, I also give full permission for any person connected with Brikhouse Boxing & Fitnessto administer first aid deemed necessary, and in case of serious

illness or injury, I give permission to call for medical and or surgical care for the child and to transport the child to a medical facility deemed necessary for the well being of the child.

Indemnification: The participant recognizes that there is risk involved in the types of activities offered by Brikhouse Boxing & Fitness. Therefore the participant accepts financial responsibility for any injury that the participant may cause either to him/herself or to any other participant due to his/her negligence. Should the above mentioned parties, or anyone acting on their behalf, be required to incur attorney's fees and costs to enforce this agreement, I agree to reimburse them for such fees and costs. I further agree to indemnify and hold harmless Brikhouse Boxing & Fitness, their principals, agents, employees, and volunteers from liability for the injury or death of any person(s) and damage to property that may result from my negligent or intentional act or omission while participating in activities offered by Brikhouse Boxing & Fitness, at the main building or abroad. This includes but is not limited to parks, recreational areas, playgrounds, areas adjacent to main building, and/or any area selected for training by Brikhouse Boxing & Fitness.

I have read and understood the foregoing assumption of risk, and release of liability and I understand that by signing it obligates me to indemnify the parties named for any liability for injury or death of any person and damage to property caused by my negligent or intentional act or omission. I understand that by signing this form I am waiving valuable legal rights.
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THE EDWARD BROWN FOUNDATION

Participant Information

Photo and Video Release

Waiver and Release of Liability