Fall 2024 — Waiver / Athlete Intake Form

Today's Date *

Parent or Guardian's Full Name *

Phone *

Email *

Athlete's First Name *

Athlete's Last Name *

Athlete DOB *

Main Sport *

Most Recent Team and Level of Play *

Injury History / Medical Information (Allergies, disorders etc) *

I consent to the use of my name, portrait, picture, photograph or video as part of Prevail Coaching promotional and teaching materials. (Facebook, Twitter, Email, YouTube, Instagram etc.) *

Yes

I/we do hereby release Prevail Coaching from all liability, claims, or causes of action of any kind whatsoever for any injury, property loss or damages resulting directly, or indirectly from my (child's) participation in this program, whether incurred in the gym, on a playing field, or otherwise in or about the buildings at the program location or those used by the program at any location or during travel to or from any location, and I/we hereby discharge Prevail Coaching from any, and all future actions, claims and demands. *

Yes

Signature *

Clear