Child’s Name: _________________________________Female:______Male:_________
City: __________________ State: __________Zip: _______Birthdate:_______________
Parents Name: ___________________________________________________________
Parent’s Cell #’s__________________________________________________________
In Case of an Emergency, :(other than parent):Name:______________________Cell #:________________
I, the undersigned, hereby state that I am the parent/legal guardian of the Participant listed above and that I give permission for him/her to attend and/or participate in this event directed by Bravo All-Stars. I understand that there is a risk that the Participant may occur or suffer illness, personal injury or other damages while attending and/or participating in such events. In consideration of the Participant being permitted to attend and/or participate in this event directed by Bravo All-Stars, I on behalf of myself and the Participant, waive, release, and forever discharge any and all rights and claims for damages that may arise now or in the future against Bravo All-Stars facilities, employees, agents, and for any personal injury, illness, or damages that the Participant or I may occur or suffer as a result of Participant’s attendance or participation in this event directed by Bravo All-Stars.
I acknowledge that I will be responsible for paying for any medical treatment that the Participant may receive as a result of injuries or illness suffered during his/her attendance and/or participation in this event directed by Bravo All-Stars. Should the Participant be injured or become ill during his/her attendance and /or participation in this event directed by Bravo All-Stars, and I am not immediately available, I authorize Bravo All-Stars to seek emergency medical attention for the Participant. Transportation, if needed will be to Winchester Hospital unless otherwise stated.
PHYSICAL INFORMATION: Please list any current or previous accidents, illness, or physical limitations that would stop or prevent your registered child from participating in the above program, otherwise state “NONE”
Any prior Medical Conditions? ____________________________________________________________
Physical Limitations or situations? Please state NONE if applicable: _______________________________
PARENTS SIGNATURE DATE
891 Woburn St. Unit 2, Wilmington, Mass. 01887 firstname.lastname@example.org 978-658-9467