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NFA GOLDBACKS CHEERLEADING CLINIC
Please thoroughly READ and ANSWER EVERY question on this form to ensure that your child is able to participate in our Goldbacks Cheerleading Clinic. Please note, your child WILL NOT be able to participate if this form is not filled out beforehand.
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Athlete's Name *
Athlete's Age *
Athlete's Grade *
Athlete's School *
Athlete's Upcoming Grade for NEXT YEAR *
Athlete's Address *
Parent/Guardian's Name/Names *
Parent/Guardian's Cell Phone # *
Parent/Guardian's Email *
*In the following sections please list each thing to the best of your ability.*
Allergies and Dietary Restrictions 
Please list, describe reaction, and management of the reaction if applicable.
Medications
Please list all medications (including over the counter or non-prescription) taken regularly.  Please inform the clinic director if your child needs assistance with the storage of daily medication.
Do you understand?
*
Does your athlete take any medicine? *
If YES, What is the dosage and what time of day does it need to be taken? If NO please respond N/A *
What is the reason for taking this medicine? *Please respond N/A if your athlete is not on any medications. *
Doctor's Name *
Doctor's Phone # *
Permission to Secure Treatment in the event of any emergency:
I Authorize the Camp Staff to secure from any licensed hospital, physician, and/or medical personnel, any and all treatment deemed necessary for my child’s immediate care and agree that I will be responsible for payment of any and all medical information contained in this form. I understand that this authorization includes transporting my child by ambulance if necessary to the nearest medical treatment facility or hospital.

Parents; By typing your name below you authorize your permission to secure treatment
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WAIVER RELEASE OF LIABILITY:
I RECOGNIZE AND ACKNOWLEDGE THAT THERE ARE CERTAIN RISKS OF PHYSICAL INJURY TO PARTICIPANTS AND I AGREE TO ASSUME THE FULL RISK OF ANY INJURIES, DAMAGES, OR LOSS REGARDLESS OF SEVERITY WHICH MY CHILD MAY SUSTAIN AS A RESULT OF PARTICIPATING IN ANY AND ALL ACTIVITIES CONNECTED WITH THE PROGRAM.
I AGREE TO WAIVE AND RELINQUISH ALL CURRENT AND UNKNOWN FUTURE CLAIMS MY CHILD MAY HAVE AGAINST NECSD, THEIR EMPLOYEES, AND VOLUNTEERS FROM ANY AND ALL CLAIMS FROM INJURY, DAMAGE, OR LOSS ARISING FROM THE ACTIVITIES OF THE PROGRAM.

I FURTHER AGREE TO INDEMNIFY AND DEFEND THE NECSD AND ITS’ EMPLOYEES AND VOLUNTEERS AGAINST, AND HOLD THEM HARMLESS FROM, ANY AND ALL CLAIMS RESULTING FROM INJURIES, DAMAGES, AND LOSSES SUSTAINED BY MY CHILD ARISING OUT OF, CONNECTED WITH, OR IN ANY WAY ASSOCIATED WITH THE ACTIVITIES OF THE PROGRAM.

I give permission for my child’s picture to be used in advertisements of NFA GOLDBACKS CHEER CLINIC.

I HAVE READ AND FULLY UNDERSTAND THE ABOVE RELEASE OF LIABILITY AND PHOTOGRAPHY RELEASE
WAIVER AND PHOTOGRAPHY RELEASE:


Parents; By Typing your name Below you agree to Release Liability 
*
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