Waiver & Liability Release | iTumble Clovis, CA

Waiver and Release of Liability and Hold Harmless Agreement

"*" indicates required fields

PARTICIPANT'S INFORMATION

Parent or Guardian Name*

First Last

Participant's Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Phone*

Email*

Age*

Date of Birth*

Grade

EMERGENCY INFORMATION

Parent/Guardian Name*

First Last

Phone*

Alternate Name*

First Last

Alternate Phone*

Alternate Relationship*

Please list any allergies or medical problems pertinent to your child’s care:

EMERGENCY MEDICAL RELEASE

Parent or Guardian's Signature*

In the event of an emergency requiring medical attention, I hereby grant consent to a physician, athletic trainer and/or other qualified medical personnel to provide medical treatment to and/or transport my child (named on reverse side). I understand that every effort will be made to contact me in order to receive my specific authorization before any treatment or hospitalization is undertaken. However, in the event of an emergency and if I cannot be reached, I give my consent to the medical care provider to perform any necessary emergency treatments. I agree to release any records necessary to the appropriate medical care provider for the purpose of treatment, referral, billing or insurance purposes.

LIABILITY WAIVER

Parent or Guardian's Signature*

I authorize [iTumble] to photograph, videotape and/or audiotape my child in promotion of [iTumble's] in home lessons/private events/camps.

PHOTO RELEASE

Parent or Guardian's Signature*

In consideration for registration of my minor child (named on reverse side) to [iTumble], I do hereby agree to release, discharge and hold harmless, [iTumble] and its employees and booster organizations of and from all causes, liabilities, damages, claims or demands resulting from injury or accident involving said my minor child while attending or participating in home lessons/private events/camps. I understand that all participants of [iTumble] home lessons/private events/camps. must be covered by medical insurance and that [iTumble] does not provide such insurance for home lessons/private events/camps. participants.

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