Fil-Am Tri Kids & Junior Program

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Membership Form

Participant Name *

Name of Kid or Junior

Participant Age *

Must be between the ages of 6-19

Emergency Contact Number *

List any food allergies *

I HEREBY ASSUME THE RISKS OF PARTICIPATING IN ALL FILAM Tri Club/ Fil-AM Kids and Junior Developmental Tri Club (the "Club") FUNCTIONS OF EVERY KIND. I acknowledge that triathlons and Club events are an extreme test of a person’s physical and mental limits and carry with them the potential for death, serious injury, and property loss. I certify that I am in good health and I am physically fit; I have sufficiently trained for participation in such events and have not been advised otherwise by a qualified medical person; and I suffer from no physical impairment which would limit my participation in any Club athletic or social function. I acknowledge that my statements on this Acknowledgement Waiver and Release from Liability ("AWRL") are being accepted by the Club and are being relied on by USATriathlon and the Club and its organizers and administrators in permitting me to participate in any organized Club function. In consideration for allowing me to become a Club member and allowing me to participate in organized Club functions I hereby irrevocably take the following action for myself, my executors, administrators, heirs, next of kin, successors and assigns: a) I AGREE to abide by the Competitive Rules adopted by USA Triathlon, including the Medical Control Rules, as they may be amended from time to time, and I acknowledge that my Club membership may be revoked or suspended for violation of the Competitive Rules; b) I WAIVE, RELEASE, AND DISCHARGE from any and all claims or liabilities for death, personal injury, property damage, theft, damages, or loss of any kind, which arise out of or relate to my membership in the Club, my participation in, or my traveling to and from any Club athletic or social function, THE FOLLOWING PERSONS OR ENTITIES: Fil Am Tri Club / Fil-AM Kids and Junior Developmental Tri Club, Club members, Club sponsors, Club attorneys, volunteers, USA Triathlon, and the officers, directors, employees, representatives and agents of any of the above; c) I AGREE NOT TO SUE any of the persons or entities mentioned above for any of the claims or liabilities that I have waived, released or discharged herein; and d) I AGREE TO INDEMNIFY, DEFEND, AND HOLD HARMLESS the persons or entities mentioned above from all damages, costs, and expenses of any kind including attorney fees that arise from or are related to my membership in the Club, my participation in, or my traveling to and from any Club athletic or social function. By signing below, I hereby authorize the Club to include my name in the newsletter and on the website. I also grant the Club express permission to use photographs of myself in the Club newsletter, Club website, or promotional materials and for submissions to newspaper articles and to Club sponsors. I HEREBY AFFIRM THAT I AM EIGHTEEN (18)YEARS OF AGE OR OLDER, I HAVE READ THIS DOCUMENT, AND UNDERSTAND ITS CONTENTS. If the applicant is under eighteen (18) years of age, their parent/guardian must sign this AWRL AND the additional release below. *

I Agree

I Do Not Agree

If applicant is under 18 years of age, a parent or guardian must execute, in addition to the foregoing AWRL, the following, for and on behalf of the minor. The undersigned _______________________________________(parent/guardian) the parent and natural guardian or legal guardian of _________________________________(minor's name) hereby executes the foregoing AWRL for and on behalf of the minor named herein. As the natural or legal guardian of such minor, I hereby bind myself, the minor and our executors, administrators, heirs, next of kin, successors and assigns to the terms of the foregoing AWRL. I represent that I have the legal capacity and authority to act for and on behalf of the minor named herein, and I agree to indemnify and hold harmless the persons or entities mentioned in the foregoing AWRL for any claims made or liabilities assessed against them as a result of any insufficiency of my legal capacity or authority to act for and on behalf of the minor in the execution of the foregoing AWRL or in the execution of this Consent. I hereby authorize any licensed physician, emergency medical technician, hospital or other medical or health care facility ("Medical Provider") to treat the minor named herein for the purpose of attempting to treat or relieve any injuries received arising out of or relation to any organized Club function. I authorize any such Medical Provider to perform all procedures deemed medically advisable in attempting to treat or relieve such injuries. I consent to the administration of anesthesia as deemed advisable during the course or such treatment. I realize and appreciate that there is a possibility of complications and unforeseen consequences in any medical treatment, and I assume any such risk for and on behalf of myself and said minor. I acknowledge that no warranty is being made as to the results of any medical treatment. NOTE: Parent/Guardian must also sign AWRL above. *

Name of Parent or Guardian

Relationship to Kid or Junior

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