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FORMS

Waiver
Medical Release

Port City Athletics
RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK AND INDEMNITY AGREEMENT
Athlete Information
Athlete Name*
First Last
Date*
MM
DD
YYYY
Parent/Guardian Information
Parent/Guardian Name*
First Last
Relationship*
Email*
Phone*
WAIVER/RELEASE*
I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IF FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.
IN CONSIDERATION OF my child/ward, being allowed to
participate in any way in all related events and activities of PORTCITY ATHLETICS, the undersigned acknowledges, appreciates, and agrees that:

• The risk of injury to my child/ward from the activities involved in these programs is significant, including the potential for permanent disability and death, and while particular rules, equipment, and personal discipline may reduce this risk, the risk of serious injury does exist; and,

• I FOR MYSELF, SPOUSE, AND CHILD/WARD, I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES, coaches, or others, and assume full responsibility for my child/ward’s participation; and,

• I willingly agree to comply with the program’s stated and customary terms, guidelines, and conditions for participation. If I observe any unusual significant concern in my child/ward’s readiness for participation and/or in the program itself, I will remove my child/ward from the participation and bring such attention of the nearest coach, staff or official immediately; and,

• I for myself, my spouse, my child/ward, and on behalf of my/our heirs, assigns, personal representatives and next of kin, HEREBY RELEASE AND HOLD HARMLESS the owners, officers, coaches, officials, agents, employees, volunteers, other participants, sponsors, advertisers, and owners/lessors of premises used by PORTCITY ATHLETICS (“Releasees”) to conduct their program, WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH, or loss or damage to person or property incident to my child/ward’s involvement or participation in these programs, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE, to the fullest extent permitted by law.

• I, for myself, my spouse, my child/ward, and on behalf of my/our heirs, assigns, personal representatives and next of kin, HEREBY INDEMNIFY AND HOLD HARMLESS all the above Releasees from any and all liabilities incident to my child/ward’s involvement or participation in these programs, EVEN IF AIRISING FROM THEIR NEGLIGENCE, to the fullest extent permitted by law.
Parent Signature*
Athlete Signature*

Port City Athletics
MEDICAL RELEASE FORM
Name of Cheerleader/Athlete*
First Last
Primary Doctor's Name*
First Last
Doctor's Phone*
Preferred Hospital*
Medical/Health Insurance Information:
Name of Policy Holder*
First Last
Employer*
Name of Insurance Provider*
Insurance Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Member ID#*
Group ID#*
List all Current Medications:
List all Allergies:
List All Medical Conditions And/Or Injuries That May Limit or Prohibit Participation in Any PCA Activity:
Date of Last Tetanus Booster:*
MM
DD
YYYY
Date of Last Physical:*
MM
DD
YYYY
*
In case of emergency, I hereby authorize my child to be treated by a qualified physician and/or taken to the hospital. I certify that my child is fully covered by the insurance policy listed above, and I agree to bear the costs of any injury to my child sustained as a result of any activity through PortCity Athletics.
I agree
Parent/Guardian Signature*
Date*
MM
DD
YYYY
Phone*

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