Costa Ritmo - Futsal
Please review and complete this waiver before participating in the clinic.
Participant Information
Full Name
First Name
Last Name
Date of Birth
-
Month
-
Day
Year
Date
Email Address
example@example.com
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Emergency Contact Information
Emergency Contact Name
First Name
Last Name
Emergency Contact Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Relationship to Participant
Medical Conditions or Allergies
Consent to Medical Treatment
I authorize staff to obtain medical treatment for the participant in case of emergency.
Assumption of Risk & Release of Liability
Photo/Video Consent
I consent to the use of photos/videos of the participant for clinic promotional purposes.
Participant Signature
Is the participant under 18 years old?
Yes
No
Parent/Guardian Name
First Name
Last Name
Parent/Guardian Signature
Submit Waiver
Submit Waiver
Should be Empty: