STUDENT
INFORMATION
Student’s
Name ________________Sex___Age___Date of Birth __/ /__
Street
Address __________________ City____________ State ___ Zip_________
Home Phone
_________________
Mom’s Name ___________________
Business Phone___________________
Dad’s Name
____________________ Business Phone___________________
Emergency
Contact _____________________ Phone ___________________
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ACKNOWLEDGMENT
OF RISK & WAIVER OF LIABILITY
As a legal
guardian of ______________, I hereby consent to the aforementioned person
participating in
I
understand that it is the express intent of Utah Elite Cheer Academy to provide
for the safety and protection of my child and, in consideration for allowing my
child to participate, I hereby release Utah Elite Cheer Academy, its officers,
employees, teachers, and coaches, from all liability for any and all damages
and injuries suffered by my child while under the instruction, supervision, or
control of Utah Elite Cheer Academy.
This
acknowledgment of risk and waiver liability, having been read thoroughly and
understood completely, is signed voluntarily as to its content and intent.
Signature
of Legal Guardian_________________________Date_____________
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PERMISSION
FOR MEDICAL TREATMENT
I authorize
the necessary steps regarding medical attention (i.e. First aid, calling
ambulance service or transporting to the hospital) and will allow authorized
staff to treat my child for any illness or injury he/she has. I have a current medical insurance policy in
force.
Past
injuries/special information we should know _________________________________
Doctor _____________________
Insurance_______________________
ID
Number___________
Signature
of Legal Guardian ___________________________________