2017-2018 JERSEY PRIDE REGISTRATION FORM
ATHLETE INFORMATION
Name:______
Address: ______
City: ______State: ______Zip: ______
Gender:______Age as of August 31, 2017: ______DOB:______
PARENT/GUARDIAN INFORMATION
Parent/Guardian 1: ______
Cell Number: ______
Other Number: ______
Email: ______
Parent/Guardian 2:______
Cell Number: ______
Other Number: ______
Email: ______
Please list any physical/psychological limitations, injuries, or weakness that may
affect the athlete’s participation and/or performance:
______
______
Medication: ______
Allergies: ______
Doctor’s name: ______
Doctor’s number: ______
Insurance Carrier: ______Policy Number: ______
Emergency Contact: ______Number: ______
JERSEY PRIDE CHEER GYM, LLCRELEASE/WAIVER AND PARTICIPATION AGREEMENT
THIS RELEASE/WAIVER AND PARTICIPATION AGREEMENT (this “Release”) executed on ______, 2017, by ______, of ______, (here and referred to as “Releasor”).
Release and Waiver - In consideration of being permitted to participate as a student of Jersey Pride Cheer Gym, LLC, Releasor, for himself/herself and his/her personal representatives, heirs, and next of kin, releases, waives, discharges and covenants not to sue Jersey Pride Cheer Gym, LLC, its directors, officers, members, employees, coaches or agents (including the Booster Club), all referred to as “Releasees” from all liability to the Releasor, his/her personal representatives, assigns, heirs and next of kin for all loss or damage, and any claim, or damage for it, on account of bodily injury or injury to the personal property or resulting in death of the Releasor, whether caused by the negligence of Releasees or otherwise while the Releasor is participating in tumbling, dancing, cheerleading or any other activity incidental thereto (herein referred to as “Cheerleading Activities”). Releasor agrees to indemnify the Releasees and each of them from any loss, liability, damage or cost Releasees may incur due to the presence of Releasor in or on Releasor’s place of business whether caused by the negligence of the Releasees or otherwise.
Releasor assumes all responsibility for and risk of bodily injury, death or property damage due to negligence of Releasees or otherwise while in or on Releasor’s place of business, and/or while competing, traveling to, working or for any purpose participating in any Cheerleading Activities or any other activity incidental thereto. Releasor further understands and agrees that activities such as tumbling, dancing, cheerleading or any other related activity involves risk, including but not limited to, serious neck and spinal injuries resulting in complete or partial paralysis, brain damage and serious injury to virtually all bones, joints, muscles and to internal organs and/or death. Releasor further understands and agrees that such safety precautions such as standard mats, pits and other safety equipment and apparatus provided for Releasor’s protection, in addition to the participation of a coach or a teacher who will assist in the performance of certain skills, may be inadequate to prevent serious injury. While the risk of harm may be limited by all safety equipment and trained coaches, it is never eliminated. Therefore, Releasor is voluntarily participating in the aforementioned activities with the knowledge of the risk involved and hereby agrees to accept any and all inherent risks of property damage, personal injury or death.
Medical Attention– Releasor further releases any employees, members or professional personnel from any claim whatsoever on account of first aid, treatment or service rendered him/her joint participation in any cheerleading activity. Furthermore, Releasor hereby gives consent for Jersey Pride Cheer Gym, LLC to provide, through any medical provider or medical staff, customary medical athletic training attendants, transportation and emergency medical services as warranted in the course of Releasor’s participation in any Cheerleading Activities.
Transportation Waiver and Release - In the event transportation is provided to an activity by Jersey Pride Cheer Gym, LLC or a staff member, Releasor hereby grants permission to travel to and from said activity in the vehicle provided and further agrees not to hold Jersey Pride Cheer Gym, LLC, instructors, directors, officers, agents, or employees liable for any accident or injury suffered or contracted in connection with such travel.
Photo Release – Releasor hereby gives Jersey Pride Cheer Gym, LLC, their assigns, licensees, successors and interests, legal representatives, and heirs, the irrevocable right to use Releasor’s name (or any fictional name), picture, portrait, or photograph in all forms and in all media and in all matters without any restrictions as to changes or alterations for advertising, trade, promotion, exhibition, or other lawful purposes. Releasor waives the right to inspect or approve the photograph(s) or finished version(s) incorporating photographs, including written copy that may be created and appear in connection therewith. Releasor hereby releases and agrees to hold harmless the photographer, his or her assignees, licensees, successors and interests, legal representatives and heirs from any liability by virtue of any blurring, distortion, alteration, optical illusion or use in composite form whether intentional or otherwise.
Miscellaneous - Releasor agrees that this Release/Waiver and Participation Agreement is intended to be as broad and inclusive as permitted by the laws of the State of New Jersey and if any portion of the Agreement is held invalid, it is agreed that the balance shall, not withstanding, continue in full legal force and effect. Releasor is of full age, competent to sign this Release (or the parent or guardian of the minor Releasor, named below has the legal authority to execute the above Release). Releasor further states that he/she has carefully read the above Release and knows the contents of the Release and signs this Release as his/her own free act. The Releasor agrees that this Release shall be binding upon a Releasor, his/her legal representatives, heirs and assigns. This Release contains the entire agreement between the parties to this Agreement and the terms of the Release are contractual and not a mere recital.
Dated:______By:______
PARENT/GUARDIAN OF RELEASOR