Louisiana CheerNastics, LLC

Medical Release & Photo/Video Release Form

Student Name:______________________________________DOB:______________________

In case of emergency call:

Name:__________________________Relation:_____________Ph. #:_____________________

Name:__________________________Relation:_____________Ph. #:_____________________

Physical Handicaps (specify body parts, weaknesses, weight problems, physical impairments,etc.):

____________________________________________________________________________________________________________________________________________________________

Chronic Ailments:

_____Asthma                                                             _____Circulatory or Heart Problems

_____Diabetes                                                            _____Epilepsy

_____Hemophilia/other bleeding problems               _____Other (Specify)

                                                                                    _______________________

Psychological Handicaps (fears, anxieties, etc.):

____________________________________________________________________________________________________________________________________________________________

Allergies:       _____Penicillin          _____Insect Bites       _____Other____________________

Accident/Health Insurance Information: (Please attach a copy of insurance card)

Company: _____________________________________ Policy #:________________________

Agent:___________________________Address:______________________________________

City:____________________ State:___________Zip:__________Phone #:_________________

Preferred Physician:_________________________________Ph. #________________________

Emergency Agreement:

In case of emergency, I hereby give permission to the physician selected by my child’s cheerleading coach/instructor to hospitalize, secure proper treatment for and to order injection, anesthesia or surgery for my child, as named above.

Parent/Guardian’s Signature:____________________________Date:______________________

Photo/Video Release:

I hereby give permission for images of my child, captured during regular and special activities through video, photo and digital camera, to be used solely for the purposes of Louisiana CheerNastics promotional material and publications, and waive any rights of compensation or ownership thereto.

Name of Participant (Please Print):____________________________________

Name of Parent/Guardian (Please Print):_______________________________

Parent/Guardian’s Signature:___________________________________Date:_______________