Waiver - Rockford Phoenix Cheerleading Club

RPCC Emergency Medical Release & Liability Waiver

Participant or a guardian, on behalf of a minor participant, must complete and submit this Rockford Phoenix Cheerleading Club (RPCC) Emergency Medical Release & Liability Waiver before participating in RPCC Programs/Events.

Participant(Required)

First Last

Gender(Required)

Birthdate(Required)

MM/DD/YYYY

Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Phone(Required)

Email(Required)

For a minor participant, enter parent/guardian’s phone and email:

Parent/Guardian Name(Required)

First Last

Phone(Required)

Other Phone

Email(Required)

Parent/Guardian Name

First Last

Phone

Other Phone

Emergency Contacts for Participant:

Name(Required)

First Last

Primary Phone(Required)

Relationship to Participant(Required)

Name

First Last

Primary Phone

Relationship to Participant

Allergies(Required)

Other Medical Conditions/Concerns

Physician

Primary Phone

Medical/Hospital Insurance Company(Required)

Phone

Policy Holder's Name(Required)

Policy Number(Required)

LIABILITY WAIVER

In consideration of being allowed to participate in any way in any Rockford Phoenix Cheerleading Club program, related events, and activities, I, the undersigned, acknowledge, appreciate, fully understand, and agree to the following terms on behalf of myself and the above listed participant, if the participant is a minor: The participant will be engaging in programs, activities, and/or related events (collectively, the “Programs”) that involve risk of serious injury, including permanent disability or death, and severe social and economic losses which might result not only from an individual’s own actions, inactions, or negligence, but also from the action, inaction, or negligence of others, the rules of the sport, or the condition of the premises or of any equipment used. There may be other unknown risks not reasonably foreseeable at this time, and I assume all the foregoing risk and accept personal responsibility for the damages following such injury, permanent disability, or death. As such, I hereby release, discharge, covenant to indemnify and not to sue the Rockford Phoenix Cheerleading Club, its directors, officers, employees, coaches, managers, agents, sponsors, contractors, associated personnel, and the owners and lessors of premises used to conduct any Program (collectively, the “Releasees”) from any and all liability to each of the undersigned and their

heirs or next of kin for any and all claims by or on behalf of the participant resulting from the participant’s involvement in the Programs and/or being transported to or from the same, which participation and transportation, after careful consideration, I hereby authorize

I am aware there are risks to the participant of exposure to a communicable disease, directly or indirectly arising out of, contributed to, by, or resulting from an outbreak of all communicable diseases, including, but not limited to, the virus “severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2)”, which is responsible for the novel Coronavirus Disease (“COVID-19”) and/or any mutation or variation thereof. I acknowledge that COVID-19 is an extremely contagious virus that spreads through person-to-person contact. By the very nature of the Programs, the participant likely will come into contact with other individuals who may expose the participant to COVID-19. I voluntarily assume the risk that exposure or infection by COVID-19 may result from the actions, omissions, or negligence of myself, any participant, or others. I agree that, in the event I suspect the participant becomes exposed to or infected by COVID-19 and I elect to seek testing and/or treatment as a result, I will be responsible for payment of any and all medical services and testing services. I voluntarily assume all of the foregoing risks and accept sole responsibility for any injury, illness, permanent disability, or death related to COVID-19 arising from or in connection with the participant’s participation in the Programs and any other Rockford Phoenix Cheerleading Club offering, gathering, event, or program, whether directly or indirectly sponsored by the Rockford Phoenix Cheerleading Club. I hereby release, discharge, covenant to indemnify and not to sue the Releasees from any and all liability to each of the undersigned and their heirs or next of kin for any and all claims by or on behalf of the participant resulting from the participant’s involvement in the Programs and possible exposure to COVID-19.

I certify that the participant has received a physical examination by a physician and has been found physically capable of participating in the Programs.

I hereby give my consent to have an athletic trainer, coach and/or doctor of medicine or dentistry or associated personnel to provide the participant with medical assistance and/or treatment and agree to be financially responsible for the cost of such assistance and/or treatment. I agree to save and hold harmless and indemnify each and all parties herein referred to as Releases from all liability, loss, cost, claim or damage whatsoever, including death or damage to property, which may be imposed upon said Releases because of any defect in or lack of such capacity to so act or caused or alleged to be caused in whole or in part by the negligence of the Releases.

I hereby consent to any and all uses and displays by the Releasees of the participant’s name, voice, likeness, image, appearance and biographical information in, on, or in connection with any pictures, photographs, audio and video recordings, digital images (collectively, the “depictions”) that are shown on websites, in television programs and advertising, sales and marketing brochures, books, magazines, all other printed and electronic forms, and media including, without limitation, for the purpose of promoting the Rockford Phoenix Cheerleading Club and/or its initiatives and the sport of cheerleading and for promotional, commercial, and other purposes as determined by the Rockford Phoenix Cheerleading Club anywhere in the world in its sole discretion. On behalf of the participant, I understand and agree that all depictions shall be the sole property of the Rockford Phoenix Cheerleading Club and neither I nor the participant shall receive any compensation in connection with their use. Further I hereby release, waive, and discharge any claims of any kind or nature arising out of or relating to the use of the depictions against the Releasees. On behalf of the participant, I have read the above waiver/release, understand, and agree that I have given up substantial rights by signing this release, and sign below voluntarily.

I, for the participant and on behalf of the participant’s heirs, assigns, personal representatives, and next of kin, HEREBY RELEASE, INDEMNIFY, AND HOLD HARMLESS THE ROCKFORD PHOENIX CHEERLEADING CLUB, its directors, officers, employees, coaches, managers, agents, sponsors, contractors, associated personnel, including those of its affiliated organizations, and the owners and lessors of premises used to conduct the Programs from any and all claims, demands, losses, and liability arising out of or related to any ILLNESS, INJURY, DISABILITY, OR DEATH the participant may suffer, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE, to the fullest extent permitted by law. I understand that this document may not be altered in any manner and that any alteration without the express written consent from the Rockford Phoenix Cheerleading Club will cause the participant to be removed from the Program. I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND AND AGREE THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.

CODE OF CONDUCT

I understand that applicable laws require an absolute commitment to an environment free from abuse, harassment, discrimination, bullying and other improper conduct. I agree to set a good example and to create a positive and safe environment. Participants, Coaches, Parents, Officials, Spectators should not be threatened, demeaned, bullied, or ridiculed. I have read, understand, and hereby agree to abide by and support the Program/Club Code of Conduct and accept that the participant and I can be removed from participating/attending the Programs for engaging in any improper conduct including but not limited to assault, abuse, verbal threats, or use of profanity.

Parent/Guardians’ Signatures are required if participant is under the age of 18. Signature is required from Participant aged 18 or older.

Parent/Guardian(Required)

First Last

Date(Required)

Parent/Guardian's Signature(Required)

Parent Guardian

First Last

Date

Parent/Guardian Signature

Participant's name(Required)

First Last

Date

Participant's Signature(Required)