MC RACE ACADEMY | LIABILITY PROTECTION WAIVER

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Please fill this form out for each participant. This form is NOT to be used for multiple participants. Thank you | MCRA *

I understand, this is for 1x participant only

Required

PARTICIPANTS NAME *

PARTICIPANTS DATE OF BIRTH *

YYYY

How many years have you been racing? *

For those individuals under the age of eighteen (18) years (minor): As the parent and natural guardian or legal guardian of the participant, I hereby agree to the foregoing Waiver of Liability and Release for, and on behalf of, the participant (player/minor) named above. I hereby bind myself, the minor, and all other assigns to the terms of the Waiver of Liability and Release. I represent and certify that I have the legal capacity and the authority to act for, and on behalf of, the minor in the execution of this Waiver of Liability and Release. *

Yes - Participant is under the age of 18 and I am signing on their behalf

Participant is over age 18 and signing themselves

If participant is under the age 18, please provide the parent or legal guardian FULL name that is agreeing to this liability waiver. If over 18, please just state this.

MATT CAMERON RACE ACADEMY may take photographs/video footage at MATT CAMERON RACE ACADEMY Training/Camps. These could be used for analysis purposes by MATT CAMERON RACE ACADEMY coaching staff, placed on the MATT CAMERON RACE ACADEMY website, or for general media / publicity purposes. The name of your child will not be published without first seeking permission. Please let us know if you are okay with this or object. *

Yes - I am fine with this

I object

Emergency contact details. Please include: Name, relationship, address, contact number and contact email. *

Please indicate below if you the athlete or your child has any current or previous medical conditions, injuries, medication, dietary requirements or other needs that the MATT CAMERON RACE ACADEMY coaches needs to be aware of. Please give full details i.e. slipped disc/broken leg, allergies/asthma and medication required/supplied: *

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