I,
___________________________, give my child, __________________________,
permission to participate and Jetz All Stars and Heart of the Village, INC
Spring Spirit Cheer & Dance Competition on
April 10,
2010. I understand that in cheerleading as in all athletic endeavors there is a
real chance of serious injury and/or sickness to my child. I agree to hold
harmless Jetz All- Stars Cheerleading, Heart of the Village, INC its officers
and assigns, their employees, and all host facilities from any liability in the
event of sickness and/or injury to my child.
I authorize NOVA Community College and Jetz All- Stars Cheerleading officers and employees to authorize transportation of my child to a licensed medical facility and/or hospital and to authorize emergency medical treatment to my child. I understand and agree that photos/videos taken at the Spring Spirit Cheer & Dance Competition event may be used for promotional purposes without compensation to any individuals or teams.
(Please PRINT clearly & fill out all sections)
Participant
Name: ______________________________________________________________________
Participant
email:
_____________________________________________ D.O.B.
____________
Address:
____________________________________________________ Apt # ___________
City: ____________________________________ State:
______________ Zip: ____________
Parents/Guardians: _____________________________________________________________________
Day
Phone:
_____________________________
Other Phone: _______________________________
Team: _________________________________ Night Phone: _______________________________
Allergies/Medical
Concerns:
______________________________________________________________
Medications:
__________________________________________________________________________
Coach:
__________________________________________ Email: ____________________________
Insurance
Provider:
____________________________________________________________________
Primary
Doctor:
_______________________________________________________________________
Policy
#: ___________________________________ Dr’s Phone:
______________________________
I
acknowledge that as the parent/guardian I have completely and accurately filled
out all information.
Parent/Guardian’s
Signature: _________________________________ Date:
___________
|
Jetz All-Stars P.0 Box 4, Sterling VA 20167 571.266.7278 · www.JetzAllstars.com |
Heart of the Village , INC 7805 Karen Forest Dr McLean, VA 22102 |