Cayla’s Power Tumbling, Cheer, and Dance Center Inc.

Liability Form

Student #1 Last Name:______First Name______

Sex___ Age____ Date of Birth______School______Grade______

Student #2 Last Name:______First Name______

Sex___ Age____ Date of Birth______School______Grade______

Student #3 Last Name:______First Name______

Sex___ Age____ Date of Birth______School______Grade______

Address______City______State_____Zip______

Home Phone ( )______Emrg.#( )______Emrg. Contact______

Mother’s Name:______Father’s Name______

Mom’s Cell:( )______Father’s Cell: ( )______

Mother’s Occupation:______Father’s Occupation:______

Title:______Title:______

Company:______Company:______

Work #: ( )______Work #: ( )______

E-mail:______E-mail:______

Are there any medical conditions or allergic reactions to which we should be alerted?

If “Yes” please explain and specify which child?

Physician______Phone #: ( )______Preferred Hospital______

Medical Ins. Co.______Policy #______Phone #: ( )______

ACKNOWLEDGMENT OF RISK AND WAIVER OF LIABILITY

As the Parent or Legal guardian of ______, and for my own behalf, the undersigned hereby consents and authorizes Cayla’s Power Tumbling, Cheer, and Dance Center, Inc. and its officers, agents, and employees (the “Company”) to allow the aforementioned person and/or myself to participate in tumbling, cheer, and dance programs offered by Company. The undersigned acknowledges and agrees that he/she understands and accepts the risks of physical injury associated with any activity involving height and motion, including but not limited to dance, gymnastics, cheerleading, trampoline, tumbling, double-mini, and related activities. The undersigned agrees to forever waive, discharge, release, acquit, and hold harmless Company and its respective officers, employees, officials, and all loss or liability, including personal injury and death, arising out of or associated with participation in Company’s programs or while under the instruction, supervision, or control of Company, its employees, officers, and agents, to the fullest extent provided by Illinois law. In the event that Illinois law provides that a parent or guardian cannot waive, release or assume liability on behalf of a minor child, then this waiver of liability shall bar the parents and/or guardians from pursuing claims on behalf of the minor child including, but not limited to, any claim for medical expenses pursuant to the Family Expense Act. The undersigned acknowledges that he/she has executed this waiver freely and voluntarily, and understands the terms set forth herein.

______/_____/____

Parent or Legal Guardian Signature Date

PERMISSION TO TREAT (optional)

I hereby give my permission to trained medical professionals to administer emergency medical treatment to my child, should sickness or accident occur in my absence.

______/_____/______

Parent or Legal Guardian Signature Date