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.
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PARTICIPANT INFORMATION CONTRACT AND RELEASE FORM FILL OUT COMPLETELY AND LEGIBLY | ||||||||||||
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PARTICIPANT’S NAME |
DATE OF BIRTH |
DATE OF REGISTRATION | ||||||||||
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STREET ADDRESS |
APT # |
CITY |
STATE |
ZIP CODE | ||||||||
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HOME PHONE |
CELL PHONE |
E-MAIL ADDRESS*** | ||||||||||
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PARENT/GUARDIAN INFORMATION | ||||||||||||
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MOTHER’S FULL NAME |
SOCIAL SECURITY NUMBER |
WORK PHONE | ||||||||||
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FATHER’S FULL NAME |
WORK PHONE | |||||||||||
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IF PARENT/GUARDIAN CANNOT BE REACHED PLEASE CONTACT |
RELATIONSHIP TO PARTICIPANT |
PHONE NUMBER | ||||||||||
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INSURANCE INFORMATION | ||||||||||||
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INSURANCE CARRIER |
GROUP # |
POLICY # | ||||||||||
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INSURANCE PHONE NUMBER |
INSURANCE COMPANY ADDRESS | |||||||||||
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PLEASE LIST ANY ALLERGIES, PHYSICAL OR MEDICAL CONDITIONS THAT WOULD LIMIT OR PROHIBIT HIM/HER FROM PARTICIPATION | ||||||||||||
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MEDICAL WAIVER / RELEASE OF RESPONSIBILTY | ||||||||||||
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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. | ||||||||||||
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PARENT/GUARDIAN’S SIGNATURE |
DATE |
PARTICIPANT’S SIGNATURE (18 OR OVER) |
DATE | |||||||||