Medical Release & Appearance Waiver

Participant's Name*

First NameLast Name

Participant's Birthdate mm/dd/yyyy*

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Mother's Name*

First NameLast Name

Mother's Cell Number*

Please enter a valid phone number.

Best Contact Email Address*

example@example.com

Father's Name*

First NameLast Name

Father's Cell Number*

Please enter a valid phone number.

Emergency Contact*

First NameLast Name

Emergency Contact Cell Number*

Please enter a valid phone number.

Family Doctor*

First NameLast Name

Health Insurance Company*

Policy #*

Have you had any serious illnesses or injuries? (if yes, please explain)*

Do you have any medical problems or allergies that may interfere?*

I understand that there are risks of physical injury (including but not limited to cuts, sprains, broken bones and/ or
catastrophic injury) associated with the activity taking place at this event. In recognition of this acknowledged risk of
injury, I knowingly and voluntarily waive all rights and or causes of action of any kind, including but limited to any and all claims of negligence, arising as a result of such activity from which liability could accrue to Victorious Elite Allstars, its owners, directors, instructors, managers, employees, substantiates, coaches, volunteers and affiliated parties (hereinafter referred to as Victorious Elite Allstars).

I hereby agree to release Victorious Elite Allstars and hold them harmless of all liability and acknowledge that I knowingly and voluntarily assume full responsibility for all risks and injury that may take place out of active participation in this program and its events on behalf of the participant.

I am aware that this is a release of liability and acknowledgment of my voluntary and knowing assumption of risk
of injury. I have signed this document voluntarily and of my own free will in exchange for the privilege of participation.

I understand that the Victorious Elite Allstars produces promotional material about their program.

I understand that the participant may be included in videotape and or photography within this program. I hereby grant Victorious Elite Allstars, its managers, owners, directors, coaches, successors, assignees, licensees, sponsors, and commercial exhibitions to exclusive right to photograph and videotape my student and further utilize the participant’s name, face, likeness, voice and appearance as part of this program’s advertising and promotion without reservation and or limitation. In granting this license, I understand that Victorious Elite Allstars is under no obligation to exercise any of these rights, licenses, and privileges herein granted.
If I am a minor, my parent and or legal guardian has signed this document releasing Victorious Elite Allstars from any such liability described above and has acknowledged that I am knowingly and voluntarily assuming all risk of injury inherent to this program and its activities and or events.

Participant's Name*

First NameLast Name

The above-named student has my permission to participate and attend the practices and events of the Victorious Elite Allstars Program. I warrant the above information is complete and correct. I also warrant that if any changes are made to my information, I will contact the staff to update my information. I have completely read and understand the above release information. I hereby authorize the event director or their agent to act in my behalf to provide emergency medical treatment. I further release the Victorious Elite Allstars program of all liabilities associated with my child’s attendance to any practice, event or competition.

I further acknowledge, understand, appreciate and agree that my child’s participation may result in possible exposure to and illness from infectious diseases, including but not limited to, MRSA, Influenza, and COVID-19. While particular rules and personal discipline may reduce this risk, the risk of serious illness and death does exist. I knowingly and freely assume all such risks, both known and unknown, even if arising from negligence of the releasees or others and assume full responsibility for my participation and exposure.

Parent Signature*

Today's Date*

Date

By clicking this submit button you agree to the term's and conditions.*

I agree.