UNIVERSITY CHEER AND TUMBLE SPORTS Home of the UCF ALL-STARS CHEER TEAMS
Temporary Contact and Medical Release Form
PRINTING DIRECTIONS: Drag and highlight the form below, Select File, then print "selection" (For best results choose landscape layout) Print out this form, fill out completely and legibly, and return to the University C.A.T.S. front office. All Participants must have this release form completely filled out and signed by parent or guardian. There will be no exceptions.
This form is for a ONE TIME TEMPORARY USE ONLY- this form does not contain the information needed to continue after one use.
UNIVERSITY CHEER AND TUMBLE SPORTS HOME OF THE UCF ALL-STARS CHEER TEAMS
PARTICIPANT INFORMATIONCONTRACT AND RELEASE FORMFILL OUT COMPLETELY AND LEGIBLY
PARTICIPANT’S NAME
DATE OF BIRTH
DATE OF REGISTRATION
STREET ADDRESS
APT #
CITY
STATE
ZIP CODE
HOME PHONE
CELL PHONE
E-MAIL ADDRESS***
PARENT/GUARDIAN INFORMATION
MOTHER’S FULL NAME
SOCIAL SECURITY NUMBER
WORK PHONE
FATHER’S FULL NAME
WORK PHONE
IF PARENT/GUARDIAN CANNOT BE REACHED PLEASE CONTACT
RELATIONSHIP TO PARTICIPANT
PHONE NUMBER
INSURANCE INFORMATION
INSURANCE CARRIER
GROUP #
POLICY #
INSURANCE PHONE NUMBER
INSURANCE COMPANY ADDRESS
PLEASE LIST ANY ALLERGIES, PHYSICAL OR MEDICAL CONDITIONS THAT WOULD LIMIT OR PROHIBIT HIM/HER FROM PARTICIPATION
MEDICAL WAIVER / RELEASE OF RESPONSIBILTY
I ACKNOWLEDGE, UNDERSTAND, AND ASSUME ALL RISKS INVOLVED IN ANY ACTIVITIES ON THESE PREMISES, INCLUDING BUT NOT LIMITED TO, CHEERLEADING AND/OR GYMNASTICS AND/OR DANCE. I FURTHER AGREE TO HOLD HARMLESS UNIVERSITY C.A.T.S., THE LOCATION’S OWNERS, OPERATORS, AND EMPLOYEES, FROM ANY AND ALL CLAIMS, SUITS, LOSSES, OR DAMAGES OF ANY NATURE WHAT SO EVER, INCLUDING BUT NOT LIMITED TO, SUCH CLAIMS THAT MAY RESULT FROM MY CHILD’S INJURY OR DEATH, WHETHER IT BE ACCIDENTAL, AS A RESULT OF NEGLIGANCE OR OTHERWISE, DURING OR ARISING IN ANY WAY FROM THE CHEERLEADING AND/OR GYMNASTICS AND/OR DANCE PROGRAMS.
I HEREBY GRANT PERMISSION TO LICENSED HOSPITAL AND/OR STAFF MEMBER TO ADMINISTER IMMEDIATE MEDICAL TREATMENT AS DEEMED NECESSARY TO MY CHILD SHOULD HE/SHE BE INJURED DURING ANY EVENT HE/SHE IS LEFT IN THE CARE OF UNIVERSITY C.A.T.S. STAFF. FURTHER, I UNDERSTAND THAT I AM RESPONSIBLE FOR PAYMENT OF EXPENSES INCURRED RELATING TO MY CHILD’S MEDICAL TREATMENT. IN SIGNING, I AFFIRM THAT I HAVE READ THIS FORM IN ITS ENTIRETY AND THAT I UNDERSTAND THE NATURE OF THE CHEERLEADING AND/OR GYMNASTICS AND/OR DANCE PROGRAM.
