Release Form

MIRA COSTA CHEER CLINIC WAIVER

I, __(PARENT/GUARDIAN)_, the undersigned parent or guardian of (CHILD), do hereby grant permission for my child (who hereinafter shall be referred to as “participant”) to participate and that the participant may receive necessary medical treatment in the event of an injury or illness. I hereby hold the students, coaches, directors and representatives harmless in the exercise of this authority. I further agree to hold harmless the MBUSD, MBX, its employees, the coaches, including its directors, officers, students, affiliates, boosters and parents who conduct the program and the school or premises in which the program is being conducted for any illness or injury incurred by participant during the course of the camp or event.

Check below to agree to the terms of the release noted above? *

YES

* Indicates required field

Parent's Email *

Phone Contact *

Parent's Name *

First

Last

Child's Name *

Child's Age *

Child's Grade (Fall 2017) *

Child's School (Fall 2017) *

How did you hear about the clinic? *

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