Club Team: ______________________________
Profile and Release Form
Name:
Parent/Guardian’s Name(s):
Address:
City: _State_ ZIP
Home Phone: ( _) Work/Cell Phone: ( )
Email Address:
Male
Female Age: Grade: DOB
School: Coach:
Club Team: Coach:
How did you hear about us?
Newspaper Mailer/Flyer Web Radio
Clinic / Camp _
Other
HEALTH HISTORY
Do you currently an injury or have you had any injuries in the last 6 months? Yes No
If So, what?
Date it began: I am still experiencing injury the injury has healed
Have you seen a medical professional for this injury? Yes No If So, whom?
Did you / are you getting any treatment?
Athletic trainer �Physical Therapy Chiropractic Surgeryother
Sports Played Position/Event
Baseball _
Basketball
Field Hockey _
Football
Golf
Gymnastics/Cheer
Ice Hockey
Lacrosse _
Soccer
Softball
Swimming
Tennis _
Track & Field
Volleyball _
X-Country
Wrestling
Other _
Specific Area(s) You Are Looking to
Improve:
Prioritize Top 3
Fitness
Weight Loss
Confidence
Agility
Quickness
Strength
Conditioning
Flexibility
Balance
Stamina
Explosiveness
Vertical Leap
Behavior / Attitude
Other
Please check all of the following that apply to you. Explain all “Yes” answers and include approximate dates:
o Are you currently under a doctor’s care?
o Have you ever had surgery?
o Are you currently taking any medications?
o Do you have any allergies?
o Have you ever been dizzy or fainted after/during exercise?
o Have you ever had chest pains after/during exercise?
o Have you ever had high blood pressure?
o Do you have a heart murmur or other heart condition?
o Have you ever had a head injury, been knocked out or unconscious?
o Have you ever had a seizure?
o Have you ever had a stinger, burner, or pinched nerve?
o Do you ever have any trouble breathing during or after exercise?
o Do you have any skin problems (rashes, itching)?
o Do you wear glasses, contacts, or protective eyewear?
o Have you had any problem with your eyes or vision??
o Do you have only one working organ of usually paired organs (eye, kidney, etc.)?
o Have you had any other medical problems (asthma, diabetes, etc.)?
o Any special precautions, instructions or medical information to ensure your safety?
Have you ever sprained, broken, dislocated, had repeated pain or swelling of any bones or joints?
Explain all “Yes” answers. Include approximate dates of each.
For and in consideration of the Athlete, , for whom I, (Name), am the legal guardian of, being accepted into
The LAB, I state and promise as follows: My child is mentally and physically capable of participation in all training. I understand that any evaluation or assessment of my
child’s physical
fitness and any recommendation of activities made by anyone at the facility shall not be a substitute for obtaining such evaluation, assessment or recommendation from
my
child’s
physician before participating in any of the training activities. My child’s participation is volu
ntary and I voluntarily permit my child to participate. My child’s participation in
training is an
inherently dangerous activity and that the risk of participation include, but are not limited to, falls, collisions, cuts, broken bones, strains, torn ligaments, concussion and
while highly
unlikely, possible death. I hereby, for myself, my child, our heirs, administrators, executors, personal representatives and assigns, forever waive, release and discha
rge any
and all rights
to claims for damages and losses, whether monetary or otherwise compensatory, that I or my child may have against: (i) The LAB; (ii) executive directors, owners, managers, officers,
employees, members, representatives, and agents; (iii) all coaches, participants, organizers, supervisors, planners, and
volunteers; and (iv) all city, county and state governments for any
and all injures sustained by me or my child arising out of association wi
th, entry in, or participation in the training and
any and all training activities. I understand and agree that medical or
other services rendered to my child by or at the insistence of any of the above parties is not an admission of liability
to
provide or continue to provide any such services and is not a waiver
by any said parties of any hereunder. I also acknowledge that should my child require transport to a medical
facility
, I must pay for such transportation and any treatment period. I further
agree now and forever to hold the above named and unnamed parties harmless and indemnify them for all
claims, damages, judgments and costs of whatever nature and form. Athletic
Revolution recommends that your child be examined by his/her physician before participation in any and all
training activities. I hereby approve of my child’s participation in training at The
LAB. If my child has a history of
heart disease, he/she will consult a physician prior to participating
in
any training activities. I hereby approve of my child’s participation at The LAB and
their training and certify that he or she is in good health and able to participate in any
activities. I understand, should an emergency condition arise, and The LAB representative will make
their best effort to contact the above referenced contact person(s) during
the physical exam.
Name Date _
Parent/Guardian Signature
click to sign
signature
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