Victory Cheer 2017-2018 Membership Packet Victory Cheer 2017-2018 - Page 14

6

2017-2018

Release Form

Athlete Name:_________________________________ Date of Birth:________________________________

Athlete Cell:___________________________________Age as of 8.31.17:___________ Grade 17-18:_______

Address:______________________________________ City / State / Zip:_____________________________

Mother Name:_________________________________ Mother Cell:_________________________________

Father Name:__________________________________ Father Cell:__________________________________

Primary Email:_________________________________ Secondary Email:____________________________

Previous Experience:_______________________________________________________________________

If new, who referred you to Victory?:___________________________________________________________

List any physical/psychological limitation, injury, learning disability, or weakness that may affect the athlete:__________________________________________________________________________________

Allergies:_________________________________________________________________________________

Insurance Carrier:_______________________________ Policy Number:______________________________

Parent/Guardian Signature:____________________________________ Date:_________________________