"fitami Athlete Application"
FitAmI APPLICANT INFORMATION Athlete Name: Date of Birth: Sex: Home Phone: Current Address: City: State: Zip Code: Email: Cell Phone: PARENT INFORMATION Parents: Address (if different from above): Home Phone: Email: Cell Phone: Email 2: Cell Phone 2: EMERGENCY CONTACT Name of relative not residing with you: Address: City: State: Zip Code: Relationship: MEDICAL INFORMATION Athlete known allergies and/or other medical conditions: Doctor's Name: Phone Number: Hospital: WAIVER INFORMATION The waiver of liability is executed in regard to my son/daughter's participation in activity involving fitami, and/or Coach Kevin Dilworth. I understand that my son/daughter is not required to participate in these activities. I understand that there are certain risks associated by participating in sports activities. I will not hold fitami Coach Kevin Dilworth "responsible" for any injuries , which may occur, as a result of my son/daughter's participation. My son/daughter has no physical limitations, which will prevent him/her from participating. I acknowledge that we have read the forgoing WAIVER OF LIABILITY, we understand completely, and agree not to hold fitami and/or Coach Kevin Dilworth, responsible for any injuries that may result from my son/daughter's participation. SIGNATURES I declare the above information provided on this form to be true and correct. Signature of Athlete Applicant: Date: Signature of Parent of Athlete: Date: