Racheal Wood Coaching 2008
Participation in Groups
Medical Form and Waiver
Name_____________________________________Date
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Home E-mail address_____________
Personal Information
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USAT # |
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First name |
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Middle name |
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Nickname |
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Home address |
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District/County |
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Home phone |
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Cellular phone and/or Work Phone |
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Work
or Day time
e-mail address |
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Birthday (MM/DD/YYYY) |
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Medical Information
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Doctor’s name |
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Address |
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Phone number |
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Blood type |
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Medical conditions |
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Allergies |
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Current medications |
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Emergency Information
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Emergency contact’s name |
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Phone number(s) |
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Health Insurance Carrier |
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Preferred Hospital |
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Waiver & Contract
Racheal Wood Training Groups Waiver for 2008
Name of Athlete ____________________________ Date
________________
Waiver & Contract
I am fully aware that participating in any exercise
program can be a potentially dangerous, hazardous
activity. I am specifically aware of the potential
dangers of participating in the Racheal Wood
Coaching Triathlon Training Groups.
In consideration of my acceptance into the Racheal
Wood Coaching Triathlon Groups , I, the undersigned
(parent or guardian if participant is under 18 years
of age) intending to be legally bound, do hereby for
myself, my heirs, executors, administrators, and
assigns, assume any and all risks of participating
in said Triathlon Training Groups, and I hereby
waive and release any and all rights and claims for
damages I may have against Racheal Wood,
representatives, successors, and assigns for any and
all injuries, all such risks being known and
appreciated by me. I hereby waive and release the
above named persons, and entities, their
representatives, employees, successors, and assigns
from any and all claims or liabilities of any kind
arising out of my participation in said training
programs, even though these claims and liabilities
might arise out of the negligence or carelessness on
the part of the persons named above. I attest and
verify that I am physically fit and prepared for the
Racheal Wood Coaching Triathlon Training Groups, and
that a licensed medical doctor has verified my
physical condition within the last six months.
I hereby assume full responsibility from any injury,
including my death occurring while participating in,
or as a result of, my participating in the Racheal
Wood Coaching Triathlon Training Groups, and hereby
release, waive, discharge and covenant not to sue
Racheal Wood, successors, representatives,
employees, assigns, or other participants in the
Racheal Wood Racheal Triathlon Groups from any and
all liability to me, my personal representatives,
heirs, successors, and assigns for any loss or
damage and claim or demands therefore on account of
injury to me, including my death, whether caused by
their negligence or carelessness in advising me
while participating in the Racheal Wood Coaching
Triathlon Training Groups. There will be no
lifeguards on duty during some of the open water
swims. I agree to swim at my own risk during those
group sessions.
You agree that this Agreement constitutes "writing
signed by you" under any applicable law or
regulation.
____ Initial here if
you would like to use this waiver form for ALL
Racheal Wood Coaching Group Opportunities for the
year (run and swim group, bricks and clinics).
This means the waiver will cover you for every
Racheal Wood Coaching Training type session for
2008.
I agree to the above:
Signature________________________________________ Initials
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