Champ Fusion
Athlete permission slip
Program Selection *
Required
Child's First Name: *
Your answer
Child's Last Name: *
Your answer
Date of Birth: *
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DD
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YYYY
Age: *
Your answer
Child's Main Teacher *
Your answer
Gender *
Physical Activity Restrictions? For the safety of your child it is important for us to understand any adjustments we may make for your child's best interest. Please let us know if there's any physical restrictions we should be aware of. *
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Primary Parent(s) or Guardian Name(s): *
Your answer
Primary Parent(s) or Guardian Email(s): *
Your answer
Primary Parent(s) or Guardian Address:
Your answer
Primary Parent(s) or Guardian Phone Number: *
Your answer
Participation Agreement *
In consideration of enrolling my child in ChampFusion’s Sports programs, I agree to release and waive all rights to sue ChampFusion, its officers, employees, agents, Contractors (Sowing Seed School), volunteers, subcontractors, and co-sponsors (“ChampFusion and Staff”), its owners and employees for any and all claims, damages, costs, attorney's fees, or causes of action which I or my child have or may have in the future, as a result of damages or injuries relating to ChampFusion’s programs and/or incident to any negligent act or omission by ChampFusion and Staff. I understand that although my child will be exposed to fundamental movements I do agree that there are risks of harm associated with participating in any physical movement activities and or ChampFusion’s Sports Programs, which may give rise to bodily injury and/or property damage. These risks include, but are not limited to, injuries that may result in physical contact with others, paralysis, and even death. I further understand and agree that there may be risks and dangers not known or reasonably foreseeable at this time. I understand and agree to waive all rights for myself and my child relating to any claims for presently unknown conditions. I also hereby agree to consent to an immediate dismissal with prejudice of all claims I or my child may bring against ChampFusion and Staff, and to pay any legal fees ChampFusion and Staff may expend to defend any action I or my child may bring. 2. I represent that I have full authority to enter into this agreement, and further agree to indemnify and hold ChampFusion harmless against claims that may be brought by any other person who claims rights effected by this agreement. 3. I agree that If any provision of this agreement is determined to be invalid, illegal or unenforceable, the remaining provisions of this agreement shall remain in full force. 4. I agree that this agreement shall be construed according to the laws of the state of New Jersey, without regard to conflict of law principles thereof or of any other jurisdiction that would cause the application of laws of any jurisdiction other than those of the State of New Jersey. 6. I have carefully read this agreement and understand that it is a binding contract. I understand all of the terms and agree to them
Medical Information *
To ensure the safety of our students please read below: I fully understand that ChampFusion and Staff are not medical care providers. By enrolling my child in ChampFusion, I represent that my child has no known medical issues that would make participation dangerous. If my child has known medical issue(s) I will communicate directly with ChampFusion directors, list precautions above and after ChampFusion staff agrees to participation, I will agree to my child’s participation and allow ChampFusion and Staff, to seek medical help for my child as instructed on file with Sowing Seed, if they believe it necessary, and further agree to pay for such medical treatment.
Media Agreement *
I permit ChampFusion to use pictures, images, or videos (“media”) of my child for its advertising and marketing, and further agree that ChampFusion owns all rights to this media and no compensation will be paid to me or my child for its use. If you do not wish for your child's photos to be utilized simply select disagree or tadpole only.
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