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Pole Vault Atlanta CLUB Form/Waiver
Pole Vault Atlanta is the premier pole vault club of Georgia.  We are are an instructional company that provides instruction to vaulters of all levels.  We teach a particular system to all of our vaulters perfected by Vitali Petrov, who has coached more Olympic Champions and world record holders than all pole vault coaches in history.  
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Athlete's first name *
Athlete's last name *
Athlete birthdate (mm/dd/yyyy) *
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DD
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Gender *
Athlete's age at the time of filling out this form *
Parent/Guardian Contact  *
Parent/Guardian Contact cell phone number *
Parent/Guardian Contact #2 *
Parent/Guardian Contact #2 cell phone number *
Parent/Guardian #1 email address -- Receives all PV-ATL emails *
Parent/guardian #2 email address --  Receives all PV-ATL emails *
Athlete email address --  Receives all PV-ATL emails (Not required but highly recommended!)
Athlete' primary address *
Athlete's school (i.e. Riverwood High School....Sutton Middle School) *
Primary physician's name & contact phone number *
Does the athlete have any medical conditions the PV-ATL Coaching Staff should be aware of?  If so, please list. *
Does the athlete have any major allergies? If so, please list. *
Does the athlete have any prior pole vault experience? If so, please explain *
Does the athlete participate in any other sports? If so, please list. *

Minor Waiver/Release    

RELEASE OF LIABILITY FOR MINOR PARTICIPANTS, PLEASE READ BEFORE SIGNING!


IN CONSIDERATION OF (Above Minor Child/Ward), my child/ward, being allowed to participate in any way in the __Pole Vault with PV-ATL( Pole Vault Atlanta ) related events and activities, the undersigned acknowledges, appreciates, and agrees that: The risk of injury to my child from the activities involved in these programs is significant, including the potential for permanent disability and death, and while particular rules, equipment, and personal discipline may reduce this risk, the risk of serious injury does exist; and,

1) FOR MYSELF, SPOUSE, AND CHILD, I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASES or others, and assume full responsibility for my child's participation; and, 


2) I willingly agree to comply with the program's stated and customary terms and conditions for participation. If I observe any unusual significant concern in my child's readiness for participation and/or in the program itself, I will remove my child from the participation and bring such attention of the nearest official immediately; and, 

3) I myself, my spouse, my child, and on behalf of my/our heirs, assigns, personal representatives and next of kin, HEREBY RELEASE AND HOLD HARMLESS PV-ATL(Pole Vault Atlanta) ; its directors, officers, officials, agents, employees, volunteers, other participants, sponsoring agencies, sponsors, advertisers, and if applicable, owners and lessors of premises used to conduct the event ("Releasers"), WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH, or loss or damage to person or property incident to my child's involvement or participation in these programs, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE, to the fullest extent permitted by law. 

4) I, for myself, my spouse, my child, and on behalf of my/our heirs, assigns, personal representatives and next of kin, HEREBY INDEMNIFY AND HOLD HARMLESS all the above Releasers from any and all liabilities incident to my involvement or participation in these programs, EVEN IF ARISING FROM THEIR NEGLIGENCE, to the fullest extent permitted by law. 


I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT. 


Yes  -  By clicking "Yes," I as the parent/guardian understand and agree to all above information -- This is my official signature as the Parent/Guardian. *
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