2018 Rumble in the Jungle Medical Release Form

2025 Rumble in the Jungle Medical Release Form
Participant's Name*

First NameLast Name
Date of Birth*

MonthDayYear
Organization/Club*
Parent/Guardian*

First NameLast Name
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Phone Number

Area CodePhone Number
Emergency Contact*

First NameLast Name
Emergency Contact Phone*

Area CodePhone Number
Insurance Company*
Policy Number
Family Physician*
Medical History (Check all that apply)*

Heart condition/diseaseDiabetesEpilepsy/seizure disorderContact LensesAsthmaNone
Clarify any check boxes above and/or any additional medical info
I certify that (Minor's Name) is physically capable and able to fulfill the necessary requirements to participate. I understand that this form legally releases all obligations and responsibilities for the medical treatment of my son/daughter in the event of illness or injury when the parent/guardian cannot be reached. I understand that I am responsible for all expenses should injury occur. I acknowledge and understand the risks involved (including, but limited to broken bones, spinal cord injuries and even death) in this event and grant permission for my child to participate. I further agree to hold harmless Wildfire Cheer, its affiliates, staff, and facility for any injury sustained as a result of my son’s /daughter’s participation. I have read the above warning and thoroughly appreciate/understand the assumption of risks inherent in cheer/dance participation.
Minor's Name*

First NameLast Name
Parent/Guardian Signature*
Today's Date*

MonthDayYear
Should be Empty:

2025 Rumble in the Jungle Medical Release Form