TUMBLE TECH ALLSTARS, LLC
MEDICAL LIABILITY/TREATMENT RELEASE AND
MEDIA RELEASE FORM
202 Suite A Tower Drive Oldsmar Florida, 34677 Phone: (813) 814-2211
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Child’s Name: ______DOB: ______Age: ______
Address: ______City: ______Zip: ______
Phone number:______Cell number:______
Mother’s Name: ______email address:______
Father’s Name: ______email address:______
Medical Information: Heart Condition: Yes/No Diabetes: Yes/No Asthma: Yes/No
List allergies, allergies to medication and other medical conditions:______
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I, the parent or legal guardian of the above named child, hereby gives my approval to participate in any/all cheerleading/ tumbling activities. I understand and acknowledge the fact that participation in sporting activities involves some degree of risk. I for myself and on behalf of my child, hereby waive, release, absolve, and agree to hold harmless TUMBLE TECH ALLSTARS, LLC and all officers, directors, and personnel, jointly and separately, from any and all activities or any claim arising out of injury to my child.
I, the parent or legal guardian, of the above named child do hereby grant consent to full authority for the rendering of assistance, care and treatment of the above named child under any circumstances which shall reasonably be deemed an emergency, including without limitations: 1) I give permission to the coaches and all other persons of authority to administer first aid to the above named child, and 2) I give permission to have the above named child transported by ambulance, police or private vehicle to a hospital or dentist office if deemed necessary by the coaches or persons of authority, and 3) I do hereby authorize the treatment of the above named child by a licensed doctor or dentist and/or hospital personnel, including without limitations any examinations, care, treatment, anesthetics, operations and/or diagnostic procedures as may be deemed necessary.
I hereby release any photos and/or video footage of the above named child that may be taken during any of our participation with TUMBLE TECH ALLSTARS, LLC. I further understand such footage will be in good taste. I also give permission for such footage to be used on the Tumble Tech All-stars, LLC website.
Parent/Guardian Print Name: ______Relationship: ______
Signature: ______Date: ______