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First Name
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Last Name
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Age
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Date of Birth
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Address
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Phone Number
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Parent/Guardian Last Name
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Parent/Guardian First Name
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Parent/Guardian Home Phone
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Parent/Guardian Cell Phone
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Parent/Guardian Email
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Does this child have any disabilities, handicaps, injuries, limitations, allergies, hemophilia, heart conditions, asthma or other respiratory conditions, diabetes or any other condition our program staff and volunteers need to be aware of? If yes, explain.
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Doctor's Name and Phone Number
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I, the undersigned, parent or legal guardian of the participant, a minor, hereby authorize the Family Wellness Center staff, coaches and other participating parents acting in good faith and in the capacity of program volunteers, to serve as agents in my absence to consent in medical, surgical, and/or dental examination or treatment in case of emergency, and/or hospital care. If there is an emergency, and I cannot be reached, please contact the following emergency contact. PLEASE WRITE EMERGENCY CONTACT FULL NAME AND PHONE NUMBER(S)
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I, the parent or guardian of the above, do hereby acknowledge the risk of physical injury during participation in an athletic activity. I further acknowledge that I will hold harmless the Ohio County Family Wellness Center from any claims arising from injury to the above named participant. I acknowledge that I release the Ohio County Family Wellness Center from any liability should my child sustain harm and/or injury while participating in said program. I agree to enroll my child in the cheerleading program under the leadership of the Ohio County Family Wellness Center staff and volunteers. I agree that should I pay in monthly installments rather than the full amount up front, my account will be drafted monthly for the program regardless of attendance. PLEASE INITIAL BELOW. By entering your initials in the box below, you are effectively providing your signature, indicating that all the information on this form is true and accurate, to the best of your knowledge.
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