Agreement to Participate in Cheerleading and Parental Consent Form

Name of Child ………………………………… Date of Birth ………………………...

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Parent/ Guardian
………………………………………………………………………………………......

Address: ……………………………………………………………………………………...
…………………….
………………………………………………………...……........................… Postcode
………………………

Tel (day): …………………………….................. Tel (evening):

……………………….................…………
Mobile: …………………………………………………….. e-mail:
……………………………........................

Does your child suffer from any medical conditions/allergies that the program should
be aware of (including any current
medication) .........................................................................................................
………...…………………….………………………………………………………………………………..
……
…...……………………………………………………………………..……………………………..
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Please provide details of medication that must be administered:
………………………………………….
…………………………………………………………………………………………………………………
…..
…………………………………………..……………………………..……………………………..
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Emergency contact details: (If different from above)

Name: ……………………………………………………………… Telephone no: ……………..
…………
Relationship to child:
……………………………………………………………………………….................

CONSENT (please read carefully)

I am aware that participating in cheerleading can be a dangerous activity involving MANY

RISKS OF INJURY. I understand that the dangers and risk of participating in cheerleading
include, but are not limited to, death, serious neck and spinal injuries and serious injury or
impairment to other aspects of my body, general health or well being. Because of the dangers
of participating in cheerleading, I recognize the importance of following the coach’s
instruction regarding playing techniques, training and team rules, and to obey such
instructions.

Parental Consent: If participant is under 18 year of age

I have read the Agreement to Participate Therefore, I understand the potential risks of injury
and the responsibilities of my son or daughter while participating in this program. I hereby
grant my permission for my son or daughter to participate in cheerdance practice.

Date: ______________________________
 Parent’s Name: ____________________
Parent’s Signature: ___________________________