Athlete Full Name
Gender
Choose one
Age of Athlete
Grade
School Attending
T-Shirt Size
What are you interested in working on? (Check all that apply)
Hurdles
Long Jump/Triple Jump
Speed Technique
How did you hear about 289SP?
Parent/Guardian Full Name
Phone
*
Email
*
City
State
Postal Code
Emergency Contact Name
Emergency Contact Phone Number
Does the participant have any known physical defect or illness that might interfere with his/her participation in strenuous activity? If so, please explain.
No
Yes - please explain under "other"
common.other_option
Does the participant have any severe allergies or reactions to drugs/medicines? If Yes - Please Explain.
No
Yes - please explain under "other"
common.other_option
Are there any emotional/social disabilities that would be helpful for us to be aware of?
No
Yes - please explain under "other"
common.other_option
Is the participant presently taking any medications or on any special diet or exercise restrictions? If yes, please list specific details. (Name of drugs, dosage, etc.)
No
Yes - please explain under "other"
common.other_option
Functions and Activities It is my understanding that participating in the programs and recreational and other activities is a privilege. Prior to my participation in such activities, I acknowledge that there are certain risks associated with the activities, including, by way of example, physical injury due to activity-related accidents, physical injury due to transportation-related accidents, illness, or even death. In addition, I acknowledge that there may be other risks inherent in these activities of which I may not be presently aware.
Yes, I acknowledge
Release of Liability By signing this Permission/Waiver Form, I expressly warrant that the child named above is capable of withstanding both the physical and mental demands of the activities discussed above. I also expressly assume all risks of the child participating in the activities, whether such risks are known or unknown to me at this time. I further release this organization and its leaders, employees, volunteers, and agents from any claim that my child may have or that I may have against them as a result of injury or illness incurred during the course of participation in the activities. This release of liability shall include (without limitation) any claims of negligence or breach of warranty. This release of liability is also intended to cover all claims that members of the child’s or my family or estate, heirs, representatives, or assigns may have against this organization or its leaders, employees, volunteers, or agents. I further agree to indemnify and hold harmless this organization and its leaders, employees, volunteers, or agents from any and all claims arising from my participation in its activities and programs, or as a result of injury or illness of my child during such activities.
Yes, I acknowledge
First Aid and Emergency Medical Treatment. I recognize that there may be occasions where the child named above may be in need of first aid or emergency medical treatment as a result of an accident, illness, or other health condition or injury. I do hereby give permission for agents of this organization to seek and secure any needed medical attention or treatment for the child named above including hospitalization, if in the agent’s opinion such need arises. In doing so I agree to pay all fees and costs arising from this action to obtain medical treatment. I give permission for attending physician(s) and other medical personnel to administer any needed medical treatment, including surgery and, again, I agree to pay for the medical treatment. I give permission for the staff to give over-the-counter medications as needed.I give permission to transport the child named above to a medical treatment center in a non-emergency vehicle in a medical emergency situation.
Yes, I acknowledge
Release to use Image and Likeness. Throughout training session staff may take photographs or video recording of participants involved in activities. Such photographs or video records may be used by staff and participants to remember the activities and participants. I consent to the use of any such audio or visual record of the child named above to be used, distributed, or displayed as agents of the organization see fit. This consent includes but is not limited to: photographs, videotape, and audio recordings.In addition, such photographs and audio/visual recordings may be used in publications or advertising materials to let others know about our trainings. These images may also be used by Wizard Performance & Rehabilitation or its agents to produce resources for additional training or other uses to promote the gym on printed material or via social media. Wizard Performance & Rehabilitation/289 Sports Performance may also make these materials available for sale to the public.
Yes, I acknowledge
No I do not consent
I represent that I am the parent/guardian of said participant, who is under 18 years of age. I have read the above Permission/Waiver Form and am fully familiar with the contents thereof.I give permission for the child named above to participate in the activities of this organization, including any special events/activities described above. In consideration for allowing the participation of the child in these activities, I hereby consent to the Permission/Waiver Form, including the Release of Liability above, on behalf of the child and agree that this Permission/Waiver Form shall be binding upon me, my family, heirs, legal representatives, successors, and assigns.
Yes, I acknowledge
Membership Cancelation and Payment. I acknowledge that unless I selected the SINGLE SESSION there will be an automatic payment pulled every 4 weeks for 3 months at a minimum. I also acknowledge that in order to cancel I must submit a written request otherwise payments will continue automatically. I will not hold 289 Sports Performance liable for additional charges beyond the allotted subscription if I do not cancel in time.
Yes, I acknowledge
Date
Parent/Guardian Signature
Clear
Submit