WAIVER

Parent/ Guardian

All forms must be completed for your athlete to participate

Parent/ Guardian Name

Address

Contact Information

Participant Information

How many participants will you be registering?

Participant #1

Participant's Name

Participant's DOB

Participant #2

Participant (2) Name

Participant's DOB

Participant #3

Participant (3) Name

Participant's DOB

I, the undersigned, as the parent(s)/guardian of the athlete listed below, give permission to Impact Athletics to act on my behalf to contact available medical provider and hereby authorize the physicians and their associates of an appropriate medical facility to perform such diagnostic, medical and/or surgical treatment on my child as may be deemed necessary in order to assure the safety of my child(ren). I fully understand that in case an ambulance is required; I am responsible for the cost. I also fully understand that cheerleading, tumbling, ninja, nerf and bounce house activities may be dangerous and my son/daughter will be exposed to risk of injury.* I hereby, give my permission in the program and activities of Impact Athletics and release the club and instructors from any liabilities resulting from participation.

Photo Release: I herby grant consent to Impact Athletics to reproduce or any photo images taken of myself or my child for advertising or promotional purposes.

Parent/ Legal Guardian Signature

Thank you for completing your safety waiver!