CONTACT INFORMATION, MEDICAL RELEASE, LIABILITY FORM, AND PHOTO RELEASE

 

Participant’s Name ___________________________________________________________________

                                                                        First                                     Middle Name                                       Last

 

Birth date ___________________________ Age__________ Gender___________ Grade__________

 

I understand by taking part in the swim team program, activities, special events, or meetings, there is a possibility of injury or sickness to my child.  Therefore, with this knowledge, I give my permission for my child to participate in these events with the MAX Aquatics and do hereby grant permission for a hospital staff member to administer immediate treatment to my child, should he/she become injured or ill while participating in these activities.

 

I further understand that serious accidents may occur while my child participates in the MAX Aquatics program and that participation in such activity may result in serious personal injuries and/or property damage.  Knowing the risks involved in such activities, I hereby agree to assume those risks, to release and hold harmless MAX Aquatics, its officers, agents, and employees from any liability to me or my heirs or assigns for damages.

 

Proof of Birth must be displayed to one of the coaches upon reception of packet.  A copy of Birth Certificate or Passport is acceptable.

 

Please check one or more of the following:

______Yes, I hereby give permission to MAX to use a photograph or video of me or my child for

possible promotional purposes.

______  No, I do not give permission to MAX to use a photograph or video of me or my child for

possible promotional purposes. 

______Yes, I hereby give permission to MAX to use a photograph of me or my child for the web.

 

______ No, I do not give permission to MAX to use a photograph of me or my child for the web.

PLEASE PRINT CLEARLY

 

Email Address required for account set-up ________________________________________________________

 

Father’s Name _______________________________  Mother’s Name __________________________________

 

Address ______________________________________________________________________________________

 

City _____________________________________________________   Zip _______________________________

 

Home Phone __________________________________    Cell Phone Father   _____________________________

 

Cell Phone Mother _____________________________   Work Phone Father ____________________________

 

Work Phone Mother____________________________    Cell # for us to text notices  ______________________

 

Insurance Company _______________________________________    Policy Number _____________________

 

Family Physician ________________________________________    Phone ______________________________

 

____________________________________________________     _________________________ Parent or Guardian Signature            Date

 

Swimmers T-Shirt Size: Youth SM____ Youth M____ Youth Lg____   Adult S____ M ____  L ____ XL ____

Office Use Only

Bronze 1___ Bronze 2___ Silver 1___ Silver 2___ Gold___ Senior Development ___Senior___

WAIVER/RELEASE OF LIABILITY

PLEASE READ CAREFULLY BEFORE SIGNING.

THIS IS A RELEASE OF LIABILITY AND WAIVER OF CERTAIN LEGAL RIGHTS.

I, the undersigned participant and parent request voluntary participation for a minor to participate in the events which are herein after referred to as the “activities” sponsored by MAX Aquatics.

 

I consent to my/minor’s participation in the activities and acknowledge that the minor and I fully understand my/minor’s participation may involve risk of serious injury or death, including losses which may result not only from my/minor’s own actions, inactions or negligence, but also from the actions, inactions, or negligence of others, the condition of the facilities, equipment, or areas where the event or activity is being conducted, and/or the rules of play of this type of event or activity. I understand that if I have any risk concerns, I should discuss the risks associated with my participation with the activity coordinators and event staff, before I sign this document and before any activities begins.

 

Release – Minor’s Rights:

In consideration of allowing Minor Participant to participate in the activities, I hereby release and hold harmless MAX Aquatics, the coaches and their members of its board of directors, officers, employees, volunteers, other participants, and agents (collectively, the “Released Parties”), of and from, and do discharge and waive, any and all claims, demands, losses, damages, and liabilities that Minor Participant may have or sustain with respect to any and all damage and/or injury, of any type, arising out of his or her participating in the activities. I also agree that if any portion of this agreement is held to be invalid the balance, notwithstanding, shall continue in full force and effect.

 

_____________________________________                      ___________________                                 ________

(Print name of Parent/Guardian)                                              (Signature of parent)                (Date)

 

Release – Parents’/Guardians’ Rights:

In consideration of allowing Minor Participant to participate in this event, I hereby release and hold harmless the Released Parties, of and from, and do discharge and waive, any and all claims, demands, losses, damages, and liabilities that I may have or sustain with respect to any and all damage and/or injury, of any type, arising from Minor Participant’s participation in the activities. I also agree that if any portion of this agreement is held to be invalid the balance, notwithstanding, shall continue in full force and effect.

 

I certify that my/minor is in good health and have no physical condition that would prevent participation in this activity. Furthermore, I agree to use my/minor’s personal medical insurance as a primary medical coverage payment if accident or injury occurs. I consent to emergency medical treatment in the event such care is required.

 

_____________________________________                      ___________________                                 ________

(Print name of Parent/Guardian)                                              (Signature of parent)                (Date)

 

Indemnification by Parent/Guardian:

The undersigned parent/guardian further agrees to indemnify, save and hold harmless the Released Parties from any and all claims, demands, losses, damages and liabilities for indemnities, contribution or otherwise with respect to any damage and/or injury, of any type, arising from Minor Participant’s participation in the activities. The undersigned also agrees that this Release and Waiver of Liability, Assumption of Risk and Indemnity Agreement extends to all acts of negligence by the Release and is intended to be as broad and inclusive as is permitted by the laws of the State in which the Event(s) is/are conducted and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.

 

_____________________________________                      ___________________                                 ________

(Print name of Parent/Guardian)                                              (Signature of parent)                (Date)