New York Xtreme, Inc.

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Registration Form

PARTICIPANT INFORMATION

* First Name:

* Last Name:

* Street:

* City:

* State:

* Zip Code:

* Home Phone:

* Birthdate:

Email:

Grade:

PARENT/GUARDIAN #1

* Firstname:

* Lastname:

EMail:

* Home Phone:

Work Phone:

* Cell Phone:

PARENT/GUARDIAN #2

Firstname:

Lastname:

Email:

Home Phone:

Work Phone:

Cell Phone:

MEDICAL/EMERGENCY CONTACT INFORMATION

* Emergency Contact:

* Phone:

Relationship to Player:

* Insurance Carrier:

* Policy #:

WAIVER INFORMATION

NY Xtreme, Inc.
Liability Release and Acknowledgement of Risk

In consideration of the services of NY Xtreme, Inc., their agents, owners, officers, employees, and all other persons or entities acting in any capacity on their behalf, I hereby agree to release and discharge NY Xtreme, Inc., on behalf of myself, my children, my parents, my heirs, assigns, personal representative and estate as follows:

1. I understand and acknowledge that the activity that I or my child are about to engage in poses known risks and unanticipated risks which could result in injury, paralysis, death, emotional distress, or damage to myself or my child, to property, or third parties. The following describe some, but not all of those risks:
Cheerleading, gymnastics, and stunting entail certain risk, which simply can not be eliminated without jeopardizing the essential qualities of the activity. Without a certain degree of risk, cheerleading/gymnastics students would not improve their skills, and the enjoyment of the sport would be diminished. Cheerleading/gymnastics expose its participants to usual risk of cuts, bruises, and other more serious injury risks. If your child is injured, you may require medical assistance at your own expense.
2. I expressly agree and promise to accept and assume all of the risks in this activity. My participation in this activity is purely voluntary, no one is forcing me or my child to participate, and we elect to participate in spite of the risks.
3. I hereby voluntarily release, forever discharge and agree to hold harmless and indemnify NY Xtreme, Inc., from any and all liability, claims, demands, actions or right of action, which are related to, arise out of, or are in any way connected with me or my child’s participation in this activity, including those allegedly attributable to the negligent acts or omission of NY Xtreme, Inc.
4. I certify that I or my child has health, accident and liability insurance to cover any bodily injury or property damage that may be caused or suffered while participating in this event, or else I agree to bear the costs of such injury or damage to myself or my child. I further certify that I or my child have no medical condition which could interfere with me or my child’s safety in this activity, or else I am willing to assume and bear the cost of all risks that may be created, directly or indirectly, by any such condition.
5. In the event of an emergency necessitating medical attention, I hereby consent and give permission to NY Xtreme, Inc., its instructors and its agents to make such decisions and to perform such medical treatment upon said minor injuries which may in their sole discretion be necessary and proper under the circumstances.

6. In the event that any pictures or video are taken, I give NY Xtreme, Inc., the right and permission to use any form for advertisements or promotional purposes.

By signing this document, I acknowledge that if anyone is hurt or property is damaged during my participation in this activity, I may be found by a court of law to have waived my right to maintain a lawsuit against NY Xtreme, Inc., its owners and instructors on the basis of my claim from which I have released them herein. I have had sufficient opportunity to read this entire document. I have read completely and understand it, and agree to be bound by its terms.

I/we agree with the above *

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