Please fill out the entire form. One form must be FULLY READ and completed for/by EACH MEMBER AND COACH. The original signed copy must be remitted to CheerExpo (do not send via fax). If your child is competing on multiple teams please remit one copy to the coach of EACH team (photocopies are permitted as long as one copy is the original).
Participants Name: ________________________________________________ Age: ______ Grade:______ Date of Birth (D/M/Y): ______________ School/Club/Team Name: ________________________________ Home Address: _________________________________________________________________________ Phone: (_______)__________________
(Include Area Code) (Please list all)
Email:_____________________________________________
Athlete Teacher Advisor Parent Ex-Athlete Other
Position of Participant (circle one):
Coach
Insurance Company*: _________________________ Policy Number*: ______________________________
(*Required for foreign and US residents only)
REQUIRED*: Canadian Residents Only. Provincial Health Program Number (i.e. Health Card Number, OHIP,
Medicare, etc): __________________________________________ Expiry Date: ______________________
(if applicable)
Medical Conditions: ______________________________________________________________________ Allergies:_______________________________________________________________________________ Parent/Guardian Name(s):_________________________________________________________________ Home Phone: (_______)___________________ Work/Cell Phone: (_______)________________________
(include area code) (include area code)
Additional Emergency Contact Name(s): ______________________________________________________ Home Phone: (_______)___________________ Work/Cell Phone: (_______)_______________________
(include area code) (include area code)
In this activity, as in all athletic activities, there is an inherent risk of injury and/or death. I do hereby on behalf of myself and/or my child, my family and friends, release and forever discharge the event facility (venue), CheerExpo Cheerleading and Dance Events Inc (CheerExpo), and their respective employees, partners, members, volunteers, instructors, exhibitors, clients, contractors, directors, speakers, officers, and owners from any and all claims, demands, and causes of action for any injury to persons or property resulting from participation in CheerExpo competitions, events, and or activities, including traveling to and/or from the event(s). I further attest and acknowledge that I/my child am/is in good medical condition and am/is physically able to participate in this event. A chaperone/adult (over the age of 21) is required to attend with participants. This chaperone will be responsible for the participants at all times. CheerExpo
