For Ages 9-12
Verification of Information, Consent to Background
Check, Permission to Use Image, Release and Waiver of Liability
I request that my child (identified above) be permitted to participate in an activity sponsored by Terance Mathis Educational Institute, Elite 1 Performance, or ESC and agree to the following: I understand and agree that my child’s participation in this activity may expose him/her to risks of injury or death. The risks include but are not limited to: death, injury, serious neck and spinal injuries, paralysis, brain damage, and injury to vital organs, bones, joints, muscles and tendons. I will counsel my child so he/she understands that it is important for his/her safety and the safety of others to follow all instructions of the coaches and staff. I agree that I am responsible for my child’s conduct while he/she is participating at the activity.
In consideration for my child’s participation in this activity, on behalf of myself and my child, I release discharge, and hold harmless the State of GA AND NM, Terance Mathis Educational Institute, Elite 1 Performance, or ESC and their officers, coaches, volunteers, employees and agents from all liability, claims, costs, and expenses arising out of these activities which may result in injury or illness to my child. I also agree to defend and indemnify the State of GA AND NM, Terance Mathis Educational Institute, Elite 1 Performance, or ESC and their officers, coaches, volunteers, employees and agents aGA and NMinst any claims arising out of my child’s participation in the activity.
I further agree that the Athletics Department Staff, the Terance Mathis Educational Institute, Elite 1 Performance, or ESC are authorized to obtain and authorize emergency medical treatment for my child up to and including emergency hospitalization and surgery. I agree to be personally responsible for any related medical expenses.
On behalf of my child, and myself, I further release the State, Terance Mathis Educational Institute, Elite 1 Performance, or ESC from any liability arising out of the emergency medical treatment obtained.
I also release Terance Mathis Educational Institute, Elite 1 Performance, or ESC from any claims for the loss of personal property and agree that Terance Mathis Educational Institute, Elite 1 Performance, or ESC may use, for publicity and advertising purposes, photographs of my child taken during participation in the activity.
A copy of this agreement shall suffice as original.
I hereby attest that the above information is true, correct, and complete. I agree and understand that as a volunteer, ESC, ELITE 1 PERFORMANCE and / or its clients are not obligated to provide me any payment or benefit for my services.
I agree to advise ESC and ELITE 1 PERFORMANCE in writing of any physical limitations which could affect or be affected by any volunteer activities I assume. I understand it is my responsibility to provide this information and I release ESC, ELITE 1 PERFORMANCE and / or its clients from any liability for injuries or illnesses which result from my failure to advise ESC and ELITE 1 PERFORMANCE in writing of any such limitations.
I understand that ESC and ELITE 1 PERFORMANCE may require a background check and I consent to such and authorize the release of the results of such a check to ESC and ELITE 1 PERFORMANCE.
I give permission to have my image/voice/photograph to be used by ESC and ELITE 1 PERFORMANCE for promotional and educational purposes. I understand that my image/voice/photo may be used to help illustrate and explain the programs of ESC, ELITE 1 PERFORMANCE and its clients.
I understand that any photographs may be used in publications, newsletters, flyers, Power Point presentations, video broadcasts, websites, etc. I also understand that photographs may also be sent to newspapers.
I, the undersigned Volunteer, in exchange for the opportunity to participate as a volunteer on behalf of Entertainment and Sports in the Community, Inc. (“ESC”), and (ELITE 1 PERFORMANCE)hereby release and discharge ESC and ELITE 1 PERFORMANCE, its employees, volunteers, board members, sponsors, promoters, and/or other agents (the “Releasees”), from all liability to me, my personal representatives, assigns, heirs, and next of kin for any and all claims, demands, actions, causes of actions, suits in equity, liabilities, and judgments of whatsoever kind or nature on account of injuries, loss, death, or other damages which I have or may incur as a result of (1) my participation in, or preparation for, ESC fundraisers, training sessions, meetings, or other ESC and ELITE 1 PERFORMANCE events, and/or (2) my presence on or around ESC and ELITE 1 PERFORMANCE premises, including travel to or from ESC and ELITE 1 PERFORMANCE fundraisers, training sessions, meetings, or other ESC and ELITE 1 PERFORMANCE events, whether while volunteering services or otherwise. I understand that this Release and Waiver of Liability Agreement includes and applies to, but is not limited to, the negligence, action or inaction of ESC and ELITE 1 PERFORMANCE and all others within the category of Releasees.
I have carefully read and voluntarily agreed to all terms above, and no oral representations, statements, or inducements apart from this written agreement have been made to me.
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