Missouri State UniversityTM

Cheerleading

2023-2024 Medical and Liability Release

Participant’s Name _______________________________________________________ Address ________________________________________________________________ City __________________________________ State _________ Zip ________________

Home Phone (_______)__________________Cell Phone (_______)_________________ Participant’s email address __________________________________________________

I hereby release Missouri State University, its Board members, officers, agents and employees (collectively  referred to as “the University”) from all claims I may have for injuries or damages, which may result from my  participation in activities with the Missouri State University Cheerleading Program, including  Tryout Clinics and Tryouts. I understand the possible risks associated with being able to participate in these  activities and release all such claims even though the claim may arise out of the negligence or carelessness  on the part of the University, or any third person, whether foreseen or unforeseen, known or unknown. I  further covenant not to sue the University for any such claim.

I authorize and provide consent for licensed medical providers to administer any medical procedure or treatment  which may be deemed medically advisable by the attending physician, including diagnostic testing and  examination should I become injured or sick while participating in activities with the Missouri State University Cheerleading Program, including tryout clinics, tryouts, and all other activities, should I be selected  as a member of the 2023-2024 Cheerleading Team.  

Participant Signature ___________________________________________________ (required)

Parent/Legal Guardian Signature _________________________________________

(required if participant is under 18 years old – I agree to all of the conditions set forth above for my son/daughter)

Missouri State University does not provide accident or health insurance, and will not pay for any medical  expenses incurred by me. Participants are required to have medical insurance and provide the information  below.

Participant Health Insurance __________________________________________________________ Participant Insurance Policy# ________________________________________________________________ Birth date ________________________________  

Emergency Contact Information: 

Name ______________________________________________________________

Address _____________________________ City/State ___________________________Zip ____________ Phone# (________) _________________________________________