Child's Name *
Date of Birth *
Child's # 2 Name
Date of Birth
Child's #3 Name
Date of Birth
Child's # 4 Name
Date of Birth
List Any Allergies or Medical Concerns Mother/Guardian Name *
Email * Primary Phone * Cell Phone Emergency Contact Name
In the event we are unable to contact the parents/guardians
Relationship to the Child Phone Number AGREEMENT *
By checking the box above, I, the undersigned parent or guardian, do hereby grant permission for my daughter/son, whose name is listed above and hereinafter shall be referred to as “participant,” to participate in the activities run at PREMIER CHEER INC. operating as Premier Academy and associated events.
PREMIER ACADEMY Directors, Agents, contractors, employees, coaches/instructors, trainers, volunteers, members and representatives are not responsible for any injury, loss or damage of any kind sustained by any person while registered as a PREMIER ACADEMY member and participating in any and all PREMIER ACADEMY sanctioned activities, events, practice sessions or social activities (all hereafter referred to as “PREMIER Activities”), including injury, death, loss or damage.
DESCRIPTION OF RISKS
DESCRIPTION OF RISKS
In consideration of my/my child’s membership and /or participation in PREMIER Activities, I acknowledge that I am aware of the possible risks, dangers and hazards associated with being a member, including the possible risk of severe or fatal injury to myself/my child or others. These risks include but are not limited to:
a) All manner of injuries resulting in muscular injuries and soft tissue injuries including bruises, scrapes, cuts etc, from executing strenuous and demanding physical techniques, collisions with walls, floor, ceilings and contact with other participants and failure in proper execution of techniques either by myself/my child or other participants;
b) all manner of injuries resulting in sprains, dislocations, concussion, broken bones, hematomas, whiplash, contusions, pulled or strained muscles, torn ligaments, muscles and tendons, joint strain and sprain, and bruising to the tail bone, wrists, legs, arms, back, neck and injuries to the gluteus maximus, pulled groin muscle, and heart attack/stroke; head, facial, eye and/or dental injuries;
c) all manner of spine or spinal cord injuries which may render me permanently paralyzed;
d) all manner of injuries, severe or fatal, resulting cuts, tears, bruises or punctures caused by shoes, finger nails, jewelry, hair accessories or props either from myself/my child or another cheerleader;
e) transmission of diseases or skin diseases in various ways and types from contact with other participants resulting in death, disease or other illnesses;
f) all manner of medical problems resulting from heat exhaustion, asthma, communicable diseases, skin rashes, and cramps;
g) all manner of internal injuries of body parts and organs, and trauma to larynx or pharynx;
h) that my/my child’s risk of injury increases as I/my child become fatigued, experience pain, frustration, and /or performance anxiety;
i) all manner of injuries and/or death that may result from transportation (all modes or types) used to and from PREMIER Activities.
In consideration of PREMIER ACADEMY allowing me/my child membership and participation in PREMIER Activities, I agree as follows:
1. TO WAIVE ANY AND ALL CLAIMS that I/my child have or may have in the future against PREMIER ACADEMY, their directors, agents, contractors, employees, coaches/instructors, trainers, volunteers, members and representatives as a result of my membership and/or participation in PREMIER Activities;
2. TO RELEASE THE CLUB from any and all liability above and beyond the provided coverage, from any loss, damage, injury or expense that I may suffer, or that my next of kin may suffer as a result of my membership and/or participation in PREMIER Activities due to any cause whatsoever, including Breach of Contract, or Breach on and Statutory or other Duty of Care, including any Duty of Care Owed under the Occupiers’ Liability Act, RSA 1980 C. 0-3 on the part of PREMIER ACADEMY;
3. TO HOLD HARMLESS AND INDEMNIFY PREMIER ACADEMY from any and all liability for any damage to the property of, or personal injury to, any third party, resulting from my membership and/or participation in PREMIER Activities;
4. TO HOLD HARMLESS AND INDEMNIFY PREMIER ACADEMY in connection with the services and/or incidents/accidents of any train, vessel, carriage, aircraft, bus, privately owned or rented motor vehicle or other conveyance, which may be used during my/my child’s membership and/or participation in PREMIER ACADEMY;
5. TO HOLD HARMLESS AND INDEMNIFY PREMIER ACADEMY for any cancellation, injury, loss accident or delay occasioned by the proprietor, employee, or service of any accommodation which may be used during my/my child’s membership and/or participation in PREMIER ACADEMY;
6. TO FOLLOW all instructions and rules given by those responsible for or in charge of any PREMIER Activities while I am/my child is a member and/or participating in PREMIER Activities. I am aware that the rules are in place to provide a safe environment for the entire membership; and
7. TO ACKNOWLEDGE and UNDERSTAND that cheerleading and tumbling requires the Coach to perform manual spotting, which involves direct physical contact and is designed to assist the participant in the safe performance of the program skills.
8. To UNDERSTAND that in case of emergency I will be contacted as soon as possible. All expenses in case of emergency will be assumed by me or my insurance carrier.
Permission is granted to use my daughter’s/son’s picture or image in any or all future advertisements, broadcasting, web site and marketing literature or promotional videos for PREMIER ACADEMY and/or and events sponsored and conducted by them. I hereby waive any right to compensation or any claim of ownership thereto.
By inputting my email address above, I agree to receive information from Premier Academy regarding classes and special events. Please note, you may opt out of this list at any time.
I have read and agree to the above Medical Release, Waiver and Media Clause. * Name of Parent/Guardian that agrees to the above statements *