Skip to content
HOME
ABOUT US
OUR MISSION
OUR HISTORY
COACHES & TRAINERS
TRAINING & CLASSES
FITNESS TRAINING
BOOT CAMP
SPEED DEVELOPMENT
STRONG START YOUTH
INJURY PREVENTION
YOUTH
SUMMER CAMP
AFTER SCHOOL
FACILITIES
CONTACT
LIABILITY & MEDIA CONSENT
24-HOUR WAIVER & CLUB PROTOCOL
Liability Waiver & Media Consent Form
jslewis
2022-12-01T10:09:26-07:00
Liability Waiver & Media Consent
Date of First Training
MM slash DD slash YYYY
How did you hear of us?
Referral? If so, their name or social media user ID?
Parent Name
First
Last
Athlete Name
(if applicable)
First
Last
Date of Birth
(Required)
MM slash DD slash YYYY
Sport
Grade
Preferred Phone #
(Required)
Parent Email Address
Athlete Email Address
Address
Street Address
Address Line 2
City
State
ZIP
Health issues/concerns we should be aware of:
WAIVER OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT
Intending to be legally bound, I do hereby, for myself, my heirs, executors, and administrators, waive, release, and forever discharge any and all of my rights of claims for damages which I or my child may have or hereafter accrue to me or my child against the staff of the
Port City Sports Performance, LLC
facility or assigns, and for any or all damages which may be sustained or suffered by me or my child in connection with this organization or with participation in events associated with this organization. All staff members have my permission to seek medical attention for my child.
- Assumption of Risks:
This use of property, facilities, staff, equipment, and/or services carries with it certain inherent risks that cannot be eliminated regardless of the care taken to avoid injuries. Some of the activities involve situations, environments, or activities that may lead to illness, physical injuries, and psychological stress or damage.
The specific risks vary from one activity to another, but the risks range from 1) minor injuries such as scratches, bruises, sprains, and embarrassment 2) major injuries such as joint or back injuries, broken bones, heart attacks, head injuries, and psychological trauma 3) catastrophic injuries including paralysis and death.
I have read the previous paragraphs and I know, understand, and appreciate these and other risks that are inherent in the activities made possible by
Port City Sports Performance, LLC
. I hereby assert that my participation is voluntary and that I knowingly assume all such risks.
- Indemnification and Hold Harmless:
I also agree to
INDEMNIFY AND HOLD
The facility in use, its owners, officers, employees, and agents HARMLESS from and all claims, actions, suits, procedures, costs, expenses, damages and liabilities, including attorney’s fees brought as a result of my involvement with
Port City Sports Performance, LLC
and to reimburse them for any such expenses incurred.
- Severability:
The undersigned further expressly agrees that the foregoing waiver and assumption of risks agreement is intended to be as broad and inclusive as permitted by the law of the State of North Carolina and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.
- Acknowledgement of Understanding:
I have read this waiver of liability, assumption of risk, and indemnity agreement, fully understand its terms, and
understand that I am giving up substantial rights, including my right to sue.
I acknowledge that I am signing the agreement freely and voluntarily, and
intend by my electronic signature to be a complete and unconditional release of all liability
to the greatest extent allowed by law.
Electronic Signature of Participant
(Required)
Date
(Required)
MM slash DD slash YYYY
Electronic Signature of Parent/Guardian
Date
MM slash DD slash YYYY
MEDIA CONSENT
I hereby give permission for [use boxes below to write participant's name] to be viewed on any media source chosen by the staff at Port City Sports Performance (PCSP) to promote the sports specific movements that are performed at PCSP and to encourage other local athletes to participate. We may show any type of your training to encourage and help the recruiting process with any university that may be interested in your athletic abilities. The media that will be chosen the most will be Youtube, Twitter, Instagram, and Facebook due to the high use of the website by most of the population, these videos will be edited in order to promote the athletic ability of the athletes demonstrating that particular movements.
Participant's Name
(Required)
First
Last
Electronic Signature of Participant
(Required)
Date
(Required)
MM slash DD slash YYYY
Electronic Signature of Parent/Guardian
Date
MM slash DD slash YYYY
Captcha Question
(Required)
CAPTCHA
Page load link
Go to Top