Liability Waiver Form

WAIVER OF LIABILITY/PERMISSION/MEDICAL RELEASE FORM

This form is required for any student, guest or individual under the age of 18 (parental signature required) participating in a NA2 Athletics or Athletic Committed Enlightened Scholars ACES event, camp, clinic, workshop, individual or group training session.

Please complete and sign this form and bring it with you prior to attending any of the above events.

Name of Student/Guest (Required)

Date of Birth (Required)

Are there any medical problems we need to know about that impact your participation in the event? (Required)

Name of Parent/Guardian (Required)

Address (Required)

City (Required)

State (Required)

Zip Code (Required)

Home Phone (Required)

Cell Phone (Required)

Who should be reached in the event of an emergency?

Name (Required)

Relationship (Required)

Telephone (Required)

I, parent/legal guardian of STUDENT (named below) give permission for the student/guest/participant named above to participate in a NA2 Athletics and Athletic Committed Enlightened Scholars ACES event, camp, clinic, workshop, individual or group training session.

I, student and/or parent, hereby release, waive, indemnify and hold harmless NA2 Athletics and Athletic Committed Enlightened Scholars ACES, including NA2 Athletics’ and Athletic Committed Enlightened Scholars ACES board members, trustees, employees, volunteer workers, students, agents, and/or representatives from any and all liability, damage, claim of any nature whatsoever, except gross negligence, arising out of or in any way related to the participation of my son/daughter and/or student/individual under my guardianship in any event, camp, clinic, individual or group training session, held by or with NA2 Athletics and Athletic Committed Enlightened Scholars ACES.

Participating in any activity is an acceptance of some risk of injury. I understand and agree that this is a responsibility of my son/daughter and/or individual under my guardianship. Despite precautions, accidents and injuries may occur and injury and/or loss or damage to personal property may occur as a result of participation. Therefore, I assume all risks related to the activities.

In case of an emergency, and if I cannot be reached, I do hereby authorize a representative of NA2 Athletics and Athletic Committed Enlightened Scholars ACES to consent to any medical treatment or care deemed advisable. I am aware that medical assistance cannot be provided by the gym providers' health center and that no NA2 Athletics and Athletic Committed Enlightened Scholars ACES employee may administer medication.

I, students and parents, have read and agree to comply with the NA2 Athletics’ Policies and Code of Conduct on the NA2 Athletics’ website, www.NA2NY.com. This includes an express acknowledgement that New York State Law prohibits all use of illegal drugs and prohibits the drinking of alcoholic beverage by persons under 21 years of age and agree that I/my daughter/son or individual under my guardianship will not use or consume alcohol or illegal drugs while participating in any NA2 Athletics and Athletic Committed Enlightened Scholars ACES event, camp, clinic, workshop, individual or group training session.

My signature below indicates that I have read, understood, and voluntarily signed this agreement. I expressly agree that this agreement shall be construed and enforced in accordance with New York State laws, and I consent to the jurisdiction of said state. I agree that this Waiver/Permission/Release is intended to be as broad and inclusive as permitted under New York State laws so that if any portion hereof is held invalid, the balance shall continue in full legal force and effect.

Parent/Guardian Name (Required)

Signature of Student/Guest (Required)