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Application and Waiver 2015-2016
Please print clearly.
Athlete Name: ________________________________________ Age as of 8/31/15: ____ D.O.B: ___/___/___
Athlete Phone number (_______)_____________________________ text? yes no
Address: ___________________________________________City: ___________________ Zip: ____________
Mothers Name: _________________________________ Phone No.: (_______) ________________ text? yes no
Fathers Name: __________________________________ Phone No.: (______) ________________ text? yes no
Parents E-mail Address ________________________________________________________________
Emergency Contact Name: _______________________________ Phone: (_______) __________________
Medical Carrier: _________________________________ Policy number:______________________________
Allergies or major injuries:__________________________________________________________________
________________________________________________________________________________________
How did you hear about us:____________________________________________________________________
As legal guardian(s) of _____________________________________________, I/ We hereby consent to the aforementioned person
participating in the Angel City Athletics LLC programs. I recognize that potentially severe injuries can occur in any activity involving height
or motion, including tumbling, stunting, and cheerleading. I understand that it is the express intent of Angel City Athletics LLC to provide
for the safety and protection of my child and, in consideration for allowing my child to use these facilities, I hereby forever release Angel
City Athletics LLC, it’s owners, employee, instructors, and coaches, from all liability for any and all damages and injuries suffered by my
child while under the instruction, supervision or control of Angel City Athletics LLC. As legal guardian of the aforementioned person, I
hereby agree to individually provide for the possible future medical expenses which may be incurred by my child as a result of any injury
sustained while training at competing or performing for Angel City Athletics LLC. In case of emergency I authorize the Angel City Athletics
LLC staff to administer first aid to my child and/or take my child to a physician or hospital for further treatment. This acknowledgement of
risk and waiver of liability, having been read thoroughly and understood completely, is signed voluntarily as to its content and intent.
Warning: lowest point of the ceiling in our practice area is 14 feet.
Publicity Release The undersigned does hereby grant Angel City Athletics LLC to produce promotional material relating to its programs, I
understand that as a participant and/or a spectator that this may include videotapes or photographs taken during the course of my team
membership. Therefore without reservation and limitations, I, in my own behalf and/or on behalf of Minor, hereby assign, transfer and grant
Angel City Athletics LLC, it’s successors, assignees, licensees, sponsors, and all other commercial exhibitors the exclusive right to
photograph and /or videotape minor and to utilize such videotapes and photographs, and minor’s name, face likeness, voice and
appearance as a part of an Event, in the advertising and promoting and Event or in advertising and promoting similar future events or
advertisements.
PARENT/LEGAL GUARDIANS CONSENT: _________________________________________ Date: ________
PARENT/LEGAL GUARDIANS CONSENT: _________________________________________ Date: ________
Address: 6515 Garfield Ave. Bell Gardens CA 90201
Website: ACAthleticscheer.weebly.com Phone: (323) 600-5568 E-mail: Coachtaniah@yahoo.com