Registration Form

Date

General Information

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Participants Name: Age: Birth Date:

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Cell# Email:

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School: Sport(s):

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Legal Parent/Guardian: Relationship to Athlete:

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Address City ZIP / Postal Code

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Work #: Email:

Emergency Contact Information:

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Name: Relationship: Cell #:

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Insurance Policy #: Hospital: Family Doctor: Phone #:

Additional Information/ Special Circumstances: (Medical Conditions, Participants living arrangements, etc.)

WAIVER AND RELEASE OF LIABILITY AGREEMENT

PLEASE NOTE: By signing in below you agree to the following terms and condition: The undersigned represents that I am at least 18 years old and am the legal parent or guardian of the minior whose name appears below (the “Participant”); and that I have the authority and legal capacity to sign this Agreement on behalf of said minor. I understand that although not likely, it is possible that Participant could be injured while participating in FitRM Academy Activities, and as a condition to his/her participating in FitRM Academy Activities, I hereby assume full responsibility for all risks arising out of, related to or connected with his/her participation in any and all FitRM Activities, including but not limited to risk of bodily injury, property damage, and death. On behalf of myself and the Participant I hereby release FitRM Academy and their respective officers, directors, employees, independent contractors, agents successors, assigns and all persons acting by, through or in concert with any of them (collectively, the “ Released Person”) from any and all actions, complaints, claims, liabilities, damages, and expenses (including attorneys’ fees and costs), whether known or unknown, including liability for bodily injury, property damage, or death, whether or not caused by the negligence of the Released will not commence or maintain, or induce other to bring or maintain any legal or administrative proceeding whatsoever or omission of any of the Released Persons relating to the FitRM Academy Activities, and will indemnify, defend and hold all Released Persons harmless for any injuries or harm to me caused by or arising out of Participant’s participation in any FitRM Activities. This Agreement is binding on me and Participant, and our respective heirs, representatives, executors, successors and assigns. If any foregoing provision, or the application thereof to any person or circumstance, shall be invalid or unenforceable the remaining provisions, and the application of such provisions to persons or circumstances other than those as to which such application is invalid or unenforceable, shall not be affected thereby.

ACKNOWLEDGED AND AGREED:

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NAME OF PARTICIPANT: PRINT NAME OF PARENT/GUARDIAN: DATE:

Signature*