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Alabama Cheerleading Center, LLC. Registration Form

I acknowledge, by my signature, that the information which I am giving is current and that I have read and agree to the conditions and rules of Alabama Cheerleading Center, LLC.

Participant_____________________________ Home Telephone _________________

Date of Birth______/______/______ Age________ Male_______ Female_______

Address________________________________________________________________

City___________________________ State __________ Zip Code_________________

Mother’s Name _______________________ Cell Telephone ___________________

Father’s Name ________________________ Cell Telephone ___________________

Emergency Contact _________________________ Telephone ___________________

E-mail Address__________________________________________________________

Please list any medications your child is currently taking, any allergies the child

may have or other noteworthy medical information:

______________________________________________________________________________

______________________________________________________________________________

The following individuals have my authorization to transport my child from the

Alabama Cheerleading Center, LLC., that the individuals named below are

the only persons to whom my child may be released:

Name: Relation:

_____________________________ _________________________________

_____________________________ _________________________________

_____________________________ _________________________________

Emergency Authorization

I understand that gymnastics and cheerleading are sports and that, as in all sports, there exists the potential for injury, minimal to catastrophic. Therefore, I authorize the Alabama Cheerleading Center, LLC. staff to take whatever emergency medical measures are deemed necessary for the protection of my child while in their care including calling

EMS for transportation to a hospital or clinic.

Insurance Company: _________________ Insurance Group Number: __________________

Insurance Contract Number:____________________

Video and Photography Release

I understand that my child’s photograph/video may be taken during the course of class instruction or during a special event. I hereby grant ____ / do not grant ____ my permission for the

resulting video / photograph to be used for any / all publicity and printing purposes.

Signature: ______________________________________ Date: _____ / _____ / _____

Registration Fee Date: _________ ‘Bama All-Stars / ACC West / ACC East (Circle One)

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