Login |  Register |  help

7 on 7 permission slip

Posted Friday, July 08, 2011 by Mike O'Donnell
Version:1.0 StartHTML:0000000228 EndHTML:0000092769 StartFragment:0000004839 EndFragment:0000092733 SourceURL:file://localhost/Users/michaelodonnell/Downloads/Blue_Streak_7_on_7_Tournament_Athlete_Info_and_waiver_2011.doc

 

 

Athlete Information

 

 
 
 


Athlete last name: _____________________   Athlete first name: _______________________ MI: ______

 

                         D.O.B. _____/_____/_____            Gender:  M     F               Grade: _______                                    Age: _______

 

                              Address: __________________________________                     Phone: ________________________________

 

                              __________________________________________        Emergency Contact: _____________________

                                             

                              __________________________________________        Emergency Phone: ______________________        

                                               City                    State                      Zip

                               

                             Email: ____________________________________                School/Organization: _____________________

                                   

                             Mother’s Full Name _________________________         Father’s Full Name _______________________

 

                       

 

Position                       Level/Division                              Team Name

1) ____________________________________________________________________________________

 

 

 

 

MEDICAL INFORMATION

 

 

YES

NO

Headaches Requiring Treatment

 

 

Heart

 

 

Breathing (i.e. asthma)

 

 

Dizzy Spells / Fainting

 

 

Black Outs

 

 

Eyes (except glasses)

 

 

Hearing or Ears

 

 

Arthritis

 

 

Knees (i.e. injury, giving out, swelling)

 

 

Spine (Back or Neck)

 

 

Broken Bones

 

 

Kidneys

 

 

Bladder

 

 

Diabetes

 

 

High Blood Pressure

 

 

Cancer

 

 

Operations or Surgery

 

 

Skin Disorders

 

 

Other Major Injuries

 

 

Drug Allergies

 

 

Eating Disorder

 

 

Allergies

 

 

 

With Explanation

YES

NO

Seizure

 

 

Explain:

 

 

 

 

 

Spine Injury

 

 

Explain:

 

 

 

 

 

Current Medications

 

 

Explain:

 

 

 

 

 

Supplements

 

 

Explain:

 

 

 

 

 

Permanent Handicap/ Disability

 

 

Explain:

 

 

 

If you have any further information that we should know about, please provide and explanation below:

(e.g. ->Allergies, Medications, Injuries, etc…)

___________________________________________________________________________________________________________________________________________________________________________

 

 


Parent Signature (If under 18) ___________________________Date __________

Athlete Signature (If over 18) ____________________________Date __________

 

 


***IMPORTANT – PLEASE READ CAREFULLY***

BLUESTREAK SPORTS TRAINING

PROGRAM ACKNOWLEDGEMENT AND RELEASE

 

I______________ (participant) and ___________________________ (parent/guardian if participant is under age 18) in consideration for my participation in the BlueStreak Sports Training Program(s) (“7 on 7 Tournament”) offered by BlueStreak Sports Training, LLC, do hereby agree to the following:

 

Program

I understand and agree that:

1.      The fee for 7 on 7 Tournament in which I am participating is $________.

2.      BlueStreak and its employees or agents have not provided me with any warranties or representations that participation in 7 on 7 Tournament will improve or enhance my performance or physical condition.

3.      BlueStreak may collect and obtain data as a result of my participation in 7 on 7 Tournament and use such information in reports or publications.  My identity may be used in advertisements for BlueStreak including but not limited to DVDs, videos, brochures, posters, and website programs.

 

Waiver and Release

I acknowledge and agree that:

By signing this document, I declare that I have no known medical problems that would preclude my participation in 7 on 7 Tournament, and the information provided to BlueStreak regarding my medical history and physical condition is, to the best of my knowledge, true and correct.  My participation in the BlueStreak program is voluntary and I assume all risk of injury or contraction of any illness or medical condition that may result, or the aggravation of any pre-existing medical condition I may have, or any damage, loss or theft of any personal property resulting or arising out of my participation in 7 on 7 Tournament.  I understand and acknowledge that BlueStreak has no expertise in diagnosing, examining, or treating any medical condition, whether existing or incurred as a result of my participation in the BlueStreak program.  I understand and acknowledge that BlueStreak has made no guaranty of success or improvement as a result of my participation in 7 on 7 Tournament.

I hereby, on behalf of myself, personal representatives, heirs, executors, administrators, agents and assigns, forever release and discharge BlueStreak, its affiliates, employees, agents, representatives, successors, and assigns from any and all claims or causes of action (known or unknown) that I may now have or will have in the future as a result of BlueStreak’s negligence.  This waiver and release of liability includes, but is not limited to, injuries that result from (a) use of any exercise equipment or facilities provided by BlueStreak, (b) use of any exercise equipment or facilities which may malfunction, (c) BlueStreak’s improper maintenance of any exercise equipment or facilities, (d) any negligent instruction or supervision provided by BlueStreak, and (e) any injuries which occur because of slipping and falling while on BlueStreak premises or equipment.  I HAVE CAREFULLY READ THIS WAIVER AND RELEASE AND FULLY UNDERSTAND THAT IT IS A COMPLETE RELEASE OF LIABILITY, THAT I HEREBY WAIVE ANY RIGHT THAT I MAY NOW HAVE OR WILL HAVE TO BRING ANY LEGAL ACTION AGAINST BLUESTREAK, ITS EMPLOYEES, AGENTS, SUCCESSORS OR ASSIGNS, FOR ANY LIABILITIES THAT MAY RESULT, WHETHER DIRECTLY OR INDIRECTLY, FROM BlueStreak NEGLIGENCE.

 

 

 

Miscellaneous

The provisions in this document are severable and if any provision is determined to be illegal or unenforceable, the remaining provisions and any partially enforceable provisions shall nevertheless be enforceable unless otherwise prohibited by the laws of the State of Connecticut.  BlueStreak’s failure to enforce any remedy or provision of this document shall not be construed as a waiver of such remedy or provision.

 

Cancellation Policy

a)      If program is cancelled 30 days prior to start date, a full refund will be issued.

b)      There is no refund once 7 on 7 Tournament has started unless an injury or a medical doctor excused illness.

c)      Cancellation of sessions during 7 on 7 Tournament must be made with at least 24 hours notification.  Failure to do so will result in a forfeiture of those sessions.

 

 

 

 

 

 

By signing below, I acknowledge that I have carefully read and fully understand this acknowledgment and release.

 


Parent Signature (If under 18) _____________________Date ______

Athlete Signature (If over 18) ______________________Date______

 

This page was created in 0.1250 seconds on server 132