Academy Form

Intake & Release Form

To ensure the safety and well being of every participant we ask that all legal guardians fill this form out. Please answer dietary restrictions, allergens, and medications to the best of your ability.
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
1) Participant Information
Participant Full Name

First NameLast Name
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
Age
Home Address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
City
State
Zip Code
School (Optional)
2) Parent / Guardian Information
Parent / Guardian Name

First NameLast Name
Relationship to Participant
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email Address
example@example.com
Secondary Emergency Contact
Emergency Contact Name

First NameLast Name
Relationship to Participant
Emergency Contact Phone
Please enter a valid phone number.Format: (000) 000-0000.
Primary Physician Phone
Please enter a valid phone number.Format: (000) 000-0000.
Known Medical Conditions
3) Allergies & Food Sensitivities
Food Allergies
Environmental Allergies
Is an EpiPen Required?
Location of EpiPen
4) Medications
Medications
May Staff Administer Medication?
Are Written Instructions Attached?
5) Dietary Restrictions
Dietary Restrictions

Other
Additional Notes on Dietary Restrictions
6) Photo, Video & Live Streaming Consent
Permissions Granted
Parent/Guardian Initials
7) Liability Waiver & Assumption of Risk
I acknowledge and accept the liability waiver and assume all risks related to participation.
Parent/Guardian Initials
8) Pickup Authorization
Authorized Pickup Persons
9) Parent / Guardian Electronic Signature
Parent / Guardian Full Legal Name

PrefixFirst NameMiddle NameLast NameSuffix
Electronic Signature
Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
By electronically signing, I certify that the information provided is accurate and I agree to the liability waiver terms.
Should be Empty:

Intake & Release Form

1) Participant Information

2) Parent / Guardian Information

Secondary Emergency Contact

3) Allergies & Food Sensitivities

4) Medications

5) Dietary Restrictions

6) Photo, Video & Live Streaming Consent

7) Liability Waiver & Assumption of Risk

8) Pickup Authorization

9) Parent / Guardian Electronic Signature