Child Group Participation Release Form

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Name *

Date of Birth *

YYYY

Age *

Parents Name *

Address *

Street, City, State and Zip

Phone Number *

Best number to reach you

Email *

Emergency Contact *

Emergency Contact Relationship *

Emergency Contact Phone *

What EMPACT event/program is your child participating in?

How did you hear about this event/program?

Release of Liability Waiver

In consideration of gaining access to participation in activities with EMPACT Tennis & Sports Performance & Sports Performance, facilities, equipment, and machinery, I do hereby waive, release, and forever discharge EMPACT Tennis & Sports Performance, its officers, agents, employees, representatives, executors, and all others from any and all responsibilities or liability for injuries or damages resulting from my participation in said program.

Please Initial *

I understand the policies and procedures set forth by EMPACT Tennis & Sports Performance and have had the opportunity to discuss my specific needs in relation to participatory activity and, as a result, I do voluntarily request the right to participate in this physically active program of exercise.

Please Initial *

I do hereby authorize EMPACT Tennis & Sports Performance and its staff to utilize any and all photographs, pictures or other likeness of me or anyone assigned guardianship to me, as they deem appropriate in its promotional materials

Please Initial *

Also, in consideration of the above factors, the undersigned participant acknowledges the existence of risks in connection with these activities, assumes such risk and agrees to accept the responsibility for any injuries sustained by the participant during the course of the session or time on the court. Most specifically, the participant acknowledges and accepts responsibility for injuries arising out of those activities which involve risk in any of the following areas:

• The use of the court or company equipment

• The performance of fitness or tennis related evaluations to assess functional capacity

• The participation in individual or group activities related to exercise, tennis instruction and activity

• Incidents which occur on the court or any other areas associated with EMPACT Tennis & Sports Performance

In addition, it is seriously recommended that participants consult with a physician before engaging in any activities associated with EMPACT Tennis & Sport Performance.

Having read the preceding, the participant acknowledges full understanding of those risks set forth herein and knowingly agrees to accept full responsibility for the participant’s own exposure to such risks and to waive full responsibility and liability on behalf of EMPACT Tennis & Sport Performance L.L.C

Child’s Name *

Parent's Signature *

Today's Date *

YYYY

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