ATHLETE INFORMATION FORM

Transcription

1 ATHLETE INFORMATION FORM School Birth Age (On 8/31/17) Athlete s Name Gender Last First MI M / F Guardian Name Gender Last First MI M / F Relationship to Athlete Address Street City State Zip Cell Phone Athlete: Parent/Guardian: Address Is it okay to include you in Team group Text? o Yes o No Address Athlete Text ( ) - Parent / Guardian Text ( ) - Name of nearest relative not living with you EMERGENCY INFORMATION Phone Allergies or Special Health Concerns: Relationship to Athlete Medical Insurance: Policy #: How did you hear about ACD? Did anyone refer you? If so, please list their name so they get credit! Signature (Guardian s signature, if minor) I understand and agree that I am responsible for payment, if balance is due. I certify this information is true and correct to the best of my knowledge. WELCOME TO ARKANSAS CHEER DYNAMIX!

2 ACKNOWLEDEMENT / AUTHORIZATION / RELEASE FORM In consideration for s participation in the activities provided by Arkansas Cheer Dynamix, including but not limited to all aspects of cheerleading, tumbling, trampoline, and dance training and/or competition, I am fully aware that any activity involving motion, height, or athletic activity creates the possibility of serious injury. I hereby release Arkansas Cheer Dynamix, including its officers, shareholders, agents, and employees, from any liability to the above named athlete, of the person claiming through him/her, arising from injury to the person or property of the above named athlete occurring on the premises of Arkansas Cheer Dynamix, including any event sponsored or sanctioned by Arkansas Cheer Dynamix, and/or travel to and from such activities. This release includes but is not limited to any claims of negligence, dangerous condition, latent defect, premises liability, code violation, negligent security, failure to warm, vicarious liability, negligent hiring, negligent supervision, negligent maintenance, or improper/dangerous equipment; it is intended to be as broad as permissible under Arkansas Law. I am fully aware of the nature of the activities provided and the possibility of injuries arising from such activities. I further agree to hold harmless, indemnify and defend Arkansas Cheer Dynamix, including its officers, shareholders, agents, and employees from any loss, liability, damage, or cost incurred by them due to the above named athlete on the premises or during any event sponsored or sanctioned by Arkansas Cheer Dynamix. This release is intended to be binding upon the athlete his/her heirs, assignees, and successor in interest, and anyone claiming by or through him/her. In addition, I have read and understood the registration form and agree to all terms as stated above. I also attest that all information given is factual. I certify that the athlete is in good health and may participate in activities at Arkansas Cheer Dynamix. In case of an emergency requiring medical treatment, the undersigned hereby authorizes Arkansas Cheer Dynamix, to take the above named athlete to a qualified medical or hospital facility for care and treatment. Athlete Name Parent, Guardian or Athlete (if 18 and over) Signature Parent, Guardian or Athlete (if 18 and over) Print Name

3 PHOTO AND VIDEO RELEASE I hereby grant Arkansas Cheer Dynamix absolute and irrevocable rights and unrestricted permission to use photos/videos taken of me/athlete or in which I may be included with others, and to use, re-use, publish and re-publish the same in whole or in part, individually or in conjunction with other photos/videos and in conjunction with any media now or hereafter known, and for illustrations, promotions, art, editorials, advertising, or any other purpose without restriction. Photos will never be used inappropratly. ATTENDANCE POLICY (New for ) After Sep 1 st, 2017, you are only allowed 3 missed practices. Excused or unexcused. After the 3 rd missed practice there will be a $50 charge. Proceeds will go to benefit the ACD Scholarship program. This policy is in place to benefit each team. Cheer is a TEAM sport and therefore we need everyone at practice each week to reach our goals. I have read understand the Arkansas Cheer Dynamix attendance policy & Photo/Video Release. Athlete Name Parent, Guardian or Athlete (if 18 and over) Signature Print Name

4 COMITMENT FORM I have read the TIME COMMITMENT/COST information and fully understand my commitment to Arkansas Cheer Dynamix outlined in the All-Star Info Packet. I understand that my commitment is for the All- Star competitive season. I understand that I am giving my credit card/debit card information and that information will be used if I do not meet payment deadlines to Arkansas Cheer Dynamix. I understand that I will forfeit any monies paid or fundraised, if I choose to leave a team or am asked to leave the program. I understand that there is a $500 Withdraw Fee that will be due if I decide to leave the program after September 1, 2017, for any reason other than season ending injury or moving out of the area. Withdraw request must be ed to cheeracd@gmail.com. I understand that I am entering into this program of my own free will. Athlete Name Parent, Guardian or Athlete (if 18 and over) Signature Parent, Guardian or Athlete (if 18 and over) Print Name Name as it appears on the card: Billing Address: Type of Card: VISA MASTER CARD DISCOVER AMERICAN EXPRESS Credit Card Number: Expiration : CVC code (back of card): Card Holder s Signature: :

5 Responsible Name: Athlete Name: Responsible Address: Responsible SSN: City, State, Zip Home #: Cell #: Draft Day each First Draft Amount Withdrawal Begin Month 1st Month Day Year Account Information (Please Choose One) ( ) Checking ( ) Savings ( ) Credit Card Name on Account: Name on Card: Routing #: Card Type: Bank Account #: Card #: Bank Name: Expiration : Security Code: I hereby authorize Arkansas Cheer Dynamix to initiate debit entries to the account indicated below via auto---pay draft system. I understand that beginning on the date listed above, Arkansas Cheer Dynamix will begin withdrawals from my bank account or credit card account. Such withdrawals will continue each month until the athlete is no longer on team, no longer has a balance or I have requested to stop auto pay draft. This form of payment can be used to pay for any items charged to my ACD account. I am aware of the $20 charge that will occur if I choose to use a credit card to draft my tuition. I further agree that should Arkansas Cheer Dynamix be notified that funds are not available in my bank account (NSF, closed account, etc.) or that a change to my account is denied, a $25 fee will be charged. I understand if I choose to discontinue this method of payment I must notify Arkansas Cheer Dynamix a minimum of seven days prior to my scheduled debit date. Signature: :

6 2017 Practice Wear Order Form Athlete s Name: ** Payment for Practice wear is DUE by May 31, INSTRUCTIONS: Girls : (Choose ONE) Either Sports Bras or Tanks tops for practice wear. You will be responsible for providing BLACK spanks to match the bras or tanks at each practice. We are NOT getting matching shorts this year. Everyone: List size for Team Tank YXXS YXS YS YM YL YXL AXS AS AM AL AXL AXXL Tank Top GIRLS OR Sports Bra EVERYONE Team Tank X X X Practice wear is required. Prep Teams are only required to purchase ONE top+tank ($75). All other teams are required to purchase 2 top + tank (Girls $125)(Guys $50-2 tanks). Girls have the option to purchase the sports bra version or the full tank version. Please put down sizes for required practice wear. If you want to buy additional pieces please make a note on the bottom of this form. Each additional Sports Bra or Full Tank = $50. (Price may increase if ordered at a later date) I want to purchase additional practice wear. YES NO If yes, what would you like to add to your order & Size? Parent Name: Parent Signature: :