Participant Waiver and Release of Liability Youth programs, classes, camps and team training. To be completed by a parent or legal guardian. A separate form is required for each participant. Fields marked * are required. Program Program name * Start date Participant Participant full name * Date of birth * Sex M F School / team Grade Parent / legal guardian Parent / guardian full name * Relationship to participant * Email address * Cell phone * Street address City State ZIP Emergency contact (other than parent / guardian above) Name * Relationship Phone * Health information Allergies Current injuries Other How did you hear about us? Waiver and release 1. Program. This waiver applies to the participant named above (“Participant”) and to Participant’s involvement in any class, camp, team training program or sponsored event offered by Momentum Performance and Wellness (“Momentum”), on or off its premises (each a “Program”). 2. Risks. Program activities may include sprinting, jumping and landing, plyometrics (including box and depth jumps), change-of-direction drills, resistance and weight training, and the use of training and measurement equipment. Risks include, but are not limited to, sprains, strains, fractures, head injuries, heat-related illness, and other injuries arising from physical exertion, equipment, or contact with other participants, and may in rare cases include serious injury, illness or death. 3. Assumption of risk. I voluntarily allow Participant to take part in the Program, and on behalf of myself and Participant, I assume all risks of injury, illness or death associated with participation. Initials * 4. Medical authorization. I authorize Momentum staff to seek emergency medical treatment for Participant if I cannot be reached. I am responsible for all medical costs incurred, and I am solely responsible for providing medical insurance coverage for Participant. Initials * 5. Release of liability. On behalf of myself, Participant, and our heirs, personal representatives, successors and assigns, I release and discharge Momentum and its affiliates, owners, directors, members, managers, employees, staff, volunteers, agents, successors and assigns, and any facilities used for the Program, from any and all claims, liabilities, damages or causes of action arising from Participant’s involvement in the Program, including claims for negligence, personal injury, illness or property damage, except those arising solely from gross negligence or willful misconduct. I knowingly give up any right I or Participant may otherwise have to bring such a legal action. Initials * 6. Indemnification. I agree to indemnify and hold harmless Momentum and the parties released above from any claims made against them in breach of this waiver, including their court costs and reasonable attorney’s fees. Initials * 7. Code of conduct. Inappropriate behavior or failure to follow Program rules or staff instructions may result in dismissal from the Program without a refund. 8. Personal property. Momentum is not responsible for the loss of, or damage to, personal property. 9. Severability. If any part of this agreement is found by a court to be against public policy or in violation of any statute or case precedent, only that wording will be removed, and the remainder of this agreement will remain in full force. 10. Media release (optional). I grant permission for photos and videos of Participant to be taken and used by Momentum for promotional or educational purposes. Yes, I grant permission No, I do not grant permission Acknowledgment. I am the parent or legal guardian of Participant and have legal authority to sign on Participant’s behalf. I have carefully read this Waiver and Release of Liability, I understand that it is a release of liability, and I sign it voluntarily. I agree to the terms above, and I agree that typing my full name below is my electronic signature. * Parent / guardian signature (type full name) * Date * Submit waiver Momentum Performance and Wellness · 125 John Roberts Road, Suite 16, South Portland, Maine 04106 · 207-347-3030 · cpribish@momentummaine.com
