Facility Use Waiver & Release Form

Facility Use Waiver and Release Form

To be read and signed by the Athlete and the Parent /Guardian if the Athlete is under 18 years old. DO NOT COMPLETE THIS FORM UNLESS DIRECTED TO DO SO. This form should be completed if participating in private lessons, independent training sessions, or facility rentals.
Participant Name*

First NameLast Name
Participant Email*
example@example.com
Participant Phone*
Please enter a valid phone number.
Age of Participant*
MVA Point of Contact Supervising Activity*
Full Name
Participant Status*

Current MVA StudentMVA AlumniNo Current MVA Affiliation
Start Date of Usage*

MonthDayYear
Date
End Date of Usage

MonthDayYear
Date
Please select all that apply*

TryoutClub ParticipantPrivate Lesson w/ MVA CoachVisiting Student-AthleteProfessional AthleteSummer Training SessionFacility Rental ParticipantEventOther
Activity*

Flag FootballGolfTennisSoftballBaseballLacrosseSwimmingGirls SoccerGirls BasketballTrack & Field/XCBoys SoccerBoys BasketballWeightliftingBeach VolleyballIndoor VolleyballOther
Parent/Guardian Name*

First NameLast Name
Parent/Guardian Email*
example@example.com
Parent/Guardian Phone*
Please enter a valid phone number.
CONSENT TO TREATMENT AND DISCLOSURE OF INFORMATION
Consent is hereby granted by the undersigned to Montverde Academy, including its Athletic Training Services staff, school nurses, health care professionals, and consultants, to proceed with any medical or minor surgical care or treatment, includingwithout limitation x-ray examination, imaging studies or testing, that the professional staff considers to be necessary for the student-athlete named below. Authorization and consent is hereby granted by the undersigned to Montverde Academy, including its Athletic Training Services staff, school nurses, health care professionals, and consultants, to obtain and release health information and records for treatment, payment,and operations purposes, including for the purpose of processing insurance claims. I understand and agree that information about my injury/condition, may be disclosed to the staff and personnel of the MVA Departments of Athletics in relation to my participation in any physical activity.This Consent to Treatment and Disclosure of Information is a required condition for participation on MVA premises and shall remainvalid until revoked in writing.
Signature of Athlete*

Clear
Date

MonthDayYear
Date
Signature of Parent/Guardian if under 18

Clear
Date

MonthDayYear
Date
ACKNOWLEDGMENT OF RISKS AND WAIVER OF CLAIMS
I understand, recognize, and acknowledge that participating in any sport or physical activity can be dangerous and can involve many risks of serious injury and/or death. I understand that the dangers and risks include, but are not limited to, serious neck and spinal injuries which may result in complete or partial paralysis, brain damage, serious injury to internal organs, bones, and other parts of the skeletal/muscular system, and other serious physical and other injuries. I understand that the dangers and risks also include other impairment of health and well-being, including impairment affecting the future ability to earn a living, engage in educational, occupational, social, and recreational activities, and generally enjoy life. I acknowledge that it is my responsibility to understand and obey instructions and rules for any sport or other physical activity or use of equipment, and to seek help from the coaching, athletic training, and other staff if I have questions. I understand that, notwithstanding precautions taken by Montverde Academy however, there are risks of serious injury and/or death. I am voluntarily participating in sports and other physical activities and using equipment while at Montverde Academy with knowledge of the dangers and risks involved. I hereby assume and accept any and all risks associated with my participation in sports or other physical activities at Montverde Academy (whether at Montverde Academy's athletic facilities or elsewhere).In consideration of being presented an opportunity to participate in sports and other physical activities at Montverde Academy and to use associated equipment, I (on behalf of myself or dependents and assigns) do hereby release, hold harmless, and forever dischargeand agree not to sue Trustees of Montverde Academy and its trustees, officers, agents, volunteers and employees from and for any and all claims, responsibilities, liabilities, demands, damages and causes of action of any nature whatsoever for, on account of, or by reason of my participation in sports or other physical activities at Montverde Academy (whether at Montverde Academy athletic facilities or elsewhere), whether or not caused by the ordinary negligence of Montverde Academy.I have read and understand this document, and I voluntarily agree to be bound by it.
Signature of Athlete/Participant *

Clear
Date

MonthDayYear
Date
Signature of Parent/Guardian if under 18

Clear
Date

MonthDayYear
Date
Should be Empty:

Facility Use Waiver and Release Form

CONSENT TO TREATMENT AND DISCLOSURE OF INFORMATION

ACKNOWLEDGMENT OF RISKS AND WAIVER OF CLAIMS