Waiver - Five Star

Parent/Guardian

All Forms must be completed for your athlete to participate

Parents / Guardian Name*

First Last

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Parents / Guardian Email*

Parents / Guardian Phone*

Participant Info

Participant(s) Address*

Street Address Address Line 2 ZIP Code

How many participants will you be registering?*

Participant #1

Participant #1 Name*

First Last

Participant #1 DOB*

Does Your Child Regularly Take Medication?*

Yes
No

Please List All Medications-- Include times and doses for administration:*

Participant #2

Participant #2 Name*

Use this section for your second child who you are signing a waiver for. Must be from the same household.

First Last

Participant #2 DOB*

Use this section for your second child who you are signing a waiver for. Must be from the same household.

Does Participant #2 Regularly Take Medication?*

Yes
No

Please List All Medications-- Include times and doses for administration:*

Participant #3

Participant #3 Name*

Use this section for your third child who you are signing a waiver for. Must be from the same household.

First Last

Participant #3 DOB*

Use this section for your third child who you are signing a waiver for. Must be from the same household.

Does Participant #3 Regularly Take Medication?*

Yes
No

Please List All Medications-- Include times and doses for administration:*

Emergency Contact Information

Emergency Contact (other than parent signing)*

First Last

Emergency Contact Phone #*

Family Doctor*

Phone*

Insurance Company*

Policy Number*

Medical Authorization and Liability Release

Medical Authorization and Liability Release: I authorize Five Star Athletics and its representatives to consent to medical treatment for my child when I cannot be reached to so consent. I am fully aware that any activity involving motion, height or athletic activities create the possibility of serious injury, paralysis or even death. I further agree to hold Five Star Athletics and its staff or volunteers harmless for any injury or resulting expense(s). I release and discharge all rights and claims against Five Star Athletics, and its parties. Five Star Athletics strives to provide the maximum in safety procedures and guidelines, and cannot assume responsibility for any accidents, injuries or illness that may occur.

Consent*

I agree to the Medical Authorization and Liability Release

Parental Consent

Parental Consent: The athlete(s) listed above has my permission to participate in the Five Star Athletics program. In consideration for the training and coaching provided by Five Star Athletics and its staff, and or volunteers. I understand that my son/daughter must abide by the rules and regulations set forth by the coaches and staff. I understand that violations of any of these rules may results in removal from the classes and or events. We acknowledge and recognize that hazards are present in any athletic event and that injury may result. Five Star Athletics coaches, staff and volunteers will not be liable for injury that occurs during cheerleading practice, contests, or travel to and from cheerleading activities.

Photo Release

Photo Release: I herby grant consent to Five Star Athletics tp reproduce or any photo images taken of myself or my child for advertising or promotional purposes.

Consent*

I agree to the Parental Consent

Signature

Signature*

Name

This field is for validation purposes and should be left unchanged.