Release & Waiver Form Participant Name *
Date of Birth *
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Allergies & Medical Conditions *
Please include any known allergies or medical conditions of this participant including any allergies to medicine.
Current Medications & Suppliments *
Please list any medications and/or supplements being taken. Include medication name, purpose, dose, and times.
Family Physician * Physician Phone Number * Parent/Guardian *
Use your information if you are over the age of 18.
Parent/Guardian Home Phone * Parent/Guardian Cell Phone * Parent/Guardian Email *
Emergency Contact *
**Other than Parent or Self.
Emergency Home Phone * Emergency Cell Phone * Covid-19 Release &Waiver *
I voluntarily assume the risk of allowing my child to participate in Inspiration Academy’s event. I voluntarily agree to assume all risks and accept sole responsibility for any illness, including but not limited to Covid-19. On behalf of myself, my child, and any successor guardian of my child, I hereby release, covenant not to sue, and agree to hold harmless 21st Century Ministries Inc. DBA Inspiration Academy, its Board Members, employees, agents, insurers, and representatives for any and all claims, liabilities, harm, damages, costs, or expenses related to any illness, including the contraction of COVID-19. By signing this Agreement, I acknowledge that I have read Inspiration Academy’s Covid-19 Response Re-Opening Plan fully and understand the contents of the Waiver. I acknowledge the risks associated with attending Inspiration Academy and the possible contraction of COVID-19 or other communicable diseases.
Click here to view full Re-Opening Plan Medical Release *
I request that in my absence the above-named participant be admitted to any hospital or medical facility for diagnosis and treatment. I request and authorize physicians, dentists, and staff, duly licensed as Doctors of Medicine or Doctors of Dentistry or other such licensed technicians or nurses to perform any diagnostic procedures, treatment procedures, operative procedures and x-ray treatment of the above participant.
Medication Release *
I here by give Inspiration Academy permission to administer over the counter medications or external preparations, in accordance with the directions of use on the container as needed. I here by release Inspiration Academy, its officers, employees, and representatives from all liability in any way resulting or arising from the administering of these medications.
Waiver, Indemnity & Assumption of Risk Agreement *
In consideration of Clairebear Properties, LLC d/b/a Inspiration Academy (hereinafter “Academy”) permitting my child (hereinafter “Child”) to participate in physical activities including but not limited to exercise, competitive sports, recreational sports, weight lifting, fitness training, conditioning and nutritional instruction (collectively referred to as “Programs”), on behalf of myself, my heirs, personal representatives, or assigns, I assume all risks and hereby release, waive, discharge, and covenant not to sue the ACADEMY, its employees, volunteers, agents and contractors, from liability from any and all claims arising from or relating to my child’s participation in the Programs.
I understand that the ACADEMY services are not a substitute for professional medical advice or a medical examination. Prior to permitting myself or my Child to participate in any ACADEMY program, activity, or exercise, I will seek the advice of a pediatrician or another health-care professional. I understand that exercise and physical activity provides certain health benefits for children, but can also cause unknown health issues and therefore should be done in moderation.
I understand that equipment commonly associated with physical fitness may be present at the site where the Programs take place, and that the presence of such equipment could result in an injury to myself or my Child. By allowing myself or my Child to participate in the Programs or any activity associated with the ACADEMY, I agree that the ACADEMY shall not be liable for any direct, indirect, special, consequential, or exemplary damages for any injury or harm to me or my Child incurred in or around the property where exercise occurs.
I agree to hold harmless and indemnify the ACADEMY, its employees, volunteers, agents, contractors and insurance carriers from all claims (whether initiated by me or by a third party) and to reimburse them for any expenses incurred because of myself or my Child’s participation in the Programs and other ACADEMY activities. I further agree to pay all expenses, including court costs and attorneys’ fees, incurred by the ACADEMY and the parties in investigating and defending a claim or suit resulting from myself or my Child’s participation in ACADEMY programs.
I further expressly agree that the foregoing waiver, indemnity and assumption of risk agreement is intended to be as broad and inclusive as is permitted by the laws of Florida, and that if any portion thereof is held invalid, it is agreed that the balance shall continue in full legal force and effect. I also agree that if legal action is brought, it must be brought in Manatee County, Florida.
I have read and agree to the terms of the policy.
Photography & Video Release *
Many photographs and video are captured at Inspiration Academy to be used in the promotion of Inspiration Academy. Marketing materials including print brochures, promotional videos, website or any other communications may be published, posted online or shared publicly with the intent to promote the Inspiration Academy.
I further release and discharge Inspiration Academy, its successors and assigns, its officers, employees and agents, and the members of the Board of Directors, from all claims and demands arising out of or about the use of such photographs, film or tape, including, but not limited to, any claims for defamation or invasion of privacy.
Acknowledgment of Understanding: I have read this waiver of liability, indemnification, and assumption of risk agreement and fully understand its terms. I understand that I am giving up substantial rights ON BEHALF OF MYSELF AND MY CHILD, including THE RIGHT to sue. I acknowledge that I am signing the agreement freely and voluntarily, and intend by my signature to be bound hereby.
By signing below, I assert that I am the person named above or parent or legal guardian of the Child named above.
Transportation Release *
I here by give Inspiration Academy permission to transport the participant to any event or activity sponsored by Inspiration Academy. I will be notified of said event.
Alternative Transportation Release *
Inspiration Academy make every effort to provide transportation to school/sport related events. Should there be a need for alternative transportation please advise your preference below. Parent/Guardians will be notified in the event Inspiration Academy Transportation is not available.
Parent/Guardian Name *
Parent/Guardian Signature *
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