Supreme Split Image Registration Form

Position of Interest

Name

First NameLast Name

Birth Date

MonthDayYear

Gender

School & Classification

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Contact Information

Parent Name

First NameLast Name

Phone Number

Format: (000) 000-0000.

Alternative Number

Format: (000) 000-0000.

E-mail

example@example.com

Jersey/Cheerleader Uniform:

Size

Quantity of Uniform(s)

Emergency Contact's Name (if different from Parent)

First NameLast Name

Relationship

Emergency Contact Phone Number

Format: (000) 000-0000.

Alt. Phone Number

Format: (000) 000-0000.

Does the athlete have any allergies, chronic illness, or medical conditions? If the athlete is prescribed an inhaler, please provide any additional information.

Medical Release and Authorization

As Parent and/or Guardian of the named athlete, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named athlete. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me.

Permission is also granted to the Supreme Split Image. and its affiliates including Directors, Coaches, and Team Parents to provide the needed emergency treatment prior to the child’s admission to the medical facility.

Release authorized on the dates and/or duration of the registered season.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.

TRAVEL DISCLOSURE, ACCIDENT WAIVER AND RELEASE OF LIABILITY FORM
I hereby assume all of the risks of participating in this Supreme Split Image programs. I certify that intended participant(s) is physically fit and have not been advised to not participate by a qualified medical professional. I certify that there are no health-related reasons or problems which preclude my participation in this Supreme camp. I acknowledge that this Accident Waiver and Travel Release of Liability Form will be used by the organizers of the Supreme Split Image in which I may participate and that it will govern my actions and responsibilities. In consideration of my application and permitting me to participate in this organization, I hereby take action for myself, my executors, administrators, heirs, next of kin, successors, and assigns as follows:
(A)I WAIVE, RELEASE, AND DISCHARGE from any and all liability, including but not limited to, the entities or persons released, for death, disability, personal injury, property damage, property theft, or actions of any kind which may hereafter occur to me including my traveling to and from events. THE FOLLOWING ENTITIES OR PERSONS: SUPREME SPLIT IMAGE, Antonio Whetstone, and/or their coaches, agents, representatives or volunteers.
(B) I INDEMNIFY, HOLD HARMLESS, AND PROMISE NOT TO SUE the entities or persons mentioned in this paragraph from any
and all liabilities or claims made as a result of participation in this Supreme Split Image, whether caused by negligence or otherwise.
I acknowledge that this activity may carry with it the potential for death, serious injury, and personal loss. The risks may
include, but are not limited to, those caused by terrain, facilities, temperature, weather, condition of participants, equipment,
vehicular traffic, actions of other people including, but not limited to, participants, volunteers, spectators, coaches, and lack of
hydration. I consent and agree that Supreme Split Image and/or their coaches, agents, representatives or volunteers may take
photographs or digital recordings of me s a participant during this event and use these in any and all media for training or
promotional purposes. I further consent that my/participants' identity may be revealed therein or by description text or commentary. I waive any rights, claims or interest and I understand that there will be no financial or other remuneration. The accident waiver, release of liability and image release shall be construed broadly to provide a release and waiver to the maximum extent permissible under applicable law.
I CERTIFY THAT I HAVE READ THIS DOCUMENT, AND I FULLY UNDERSTAND ITS CONTENT. I AM AWARE THAT THIS IS A RELEASE OF LIABILITY AND A CONTRACT AND I SIGN IT ON MY OWN FREE WILL.

PARENT/GUARDIAN WAIVER FOR MINORS (under 18 years old)
The Undersigned parent and or natural guardian does hereby represent that he/she is, in fact, acting in such capacity, has
consented to his/her child or ward’s participation in the Sports Camp, and has agreed individually and on behalf of the child or ward, to the terms of the accident waiver and release of liability set forth above. The undersigned parent or guardian further
agrees to save and hold harmless and indemnify each and all parties referred to above from all liability, loss, cost, claim, or
damage whatsoever which may be imposed upon said parties because of any defect on lack of such capacity to so act and
release said parties on behalf of the minor and the parents or legal guardian.

Date

Signature

REGISTRATION