If you are attempting to complete this waiver from a mobile phone, please click on the following link. http://www.emailmeform.com/builder/form/5fWxO3udeHI54 In an attempt to go paperless, our waiver is now online. Please fill out the all of the required fields and hit submit. There is no need to fill out a paper waiver once this electronic waiver is digitally signed. One online waiver will need to be filled out for each individual participant. Thank you.

PARENT/GUARDIAN INFO

Name *

Prefix

First *

Last *

Suffix

Address *

City *

State

AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyoming

Zip *

Cell Number *

### - ### - ####

Cell Phone Carrier: ATT, Verizon, etc *

This is for text updates on classes or emergency notifications only.

Home Number *

### - ### - ####

Email *

Confirm Email *

How Did you Hear About TTA? *

Past Participant   Flier   Email   Forwarded Email   Coach   Friend/Teammate   Newspaper/Media   Internet Search   Facebook   Yelp   Other

PARTICIPANT INFORMATION

Name *

Prefix

First *

Last *

Suffix

Gender *

Male   Female

Birthday *

MM / DD / YYYY

School *

Insurance Carrier *

Policy Number *

Medical Conditions *

None   Yes (Please Explain Below)

Ex: asthma, adhd, peanut allergies, seizures, other.

Please select the location(s) you plan attending a camp or training. Please check all that may apply *

San Ramon (TTA Beta Court)   Alameda (Bladium)   Bishop O'Dowd   Town of Danville   Piedmont   Other: After school program

TERMS AND CONDITIONS Please read the entire release form and digitally sign with your initials below

Triple Threat Academy RELEASE OF LIABILITY/ASSUMPTION OF RISK/INDEMNITY: I, the undersigned, do hereby waive, release, and discharge all claims for damages, death, personal injury which may occur or which may hereafter accrue to my child as a result of participation in Triple Threat Academy Camps. Knowing the risks of the activity, I hereby agree to assume those risks. This release is intended to discharge and hold harmless Triple Threat Academy, LLC and its employees from liability. This waiver and assumption of risk is to be binding on my heirs and assigns. I further understand that photographs may be taken of my child during the course of the clinic and these may be used in Triple Threat Academy, LLC publications. Please consult a physician before beginning any type of exercise program. Cancellation and Refund Policy Refunds will be issued in camp, group workout or private training credit only, no exceptions. Please make sure you check the dates of camps or classes prior to registering. Thank you. Bladium Sports Club RELEASE OF LIABILITY/ASSUMPTION OF RISK/INDEMNITY I DO HEREBY ASSUME FULL RESPONSIBILITY FOR ANY AND ALL DAMAGES, INJURIES (INCLUDING DEATH), OR LOSSES THAT I MAY SUSTAIN OR INCUR, IF ANY, WHILE ATTENDING, PRACTICING, OR WITNESSING IN ANY CLUB EXERCISE PROGRAM, SPORT OR PHYSICAL ACTIVITY OCCURRING IN OR ABOUT THE CLUB PREMISES (INCLUDING THE ENTIRE INDOOR AREA AND THE OUTDOOR PARKING AREA). I HEREBY ASSUME FULL RISK, WAIVE ALL CLAIMS AND RELEASE AND HOLD BLADIUM SPORTS AND FITNESS CLUBS, ITS INSTRUCTORS OR PARTNERS OF SAID PROGRAMS, INDIVIDUALLY OR OTHERWISE, HARMLESS FOR ANY AND ALL CLAIMS FOR INJURIES OR DAMAGES. In consideration of my participation in and the use of the Club’s facilities, I hereby release and covenant not to sue the club, its owners, shareholders, directors, officers, employees, representatives, agents, and lessees from any and all present claims resulting from ordinary negligence and inherent risk of use of the facilities and equipment of the club including but not limited to any loss, injury, damage or liability sustained by me while on or about the premises of the club. In consideration of my child’s participation in and the use of the Club’s facilities, I hereby release and covenant not to sue the club, its owners, shareholders, directors, officers, employees, representatives, agents, and lessees from any and all present claims resulting from ordinary negligence and inherent risk of use of the facilities and equipment of the club including but not limited to any loss, injury, damage or liability sustained by my child while on or about the premises of the club. I HAVE READ AND FULLY UNDERSTAND THE ABOVE RELEASE/WAIVER AND FULLY UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING THIS WAIVER VOLUNTARILY.

Do you agree with the terms and conditions? *

Yes, I agree.

Initial *

Today's Date *

MM / DD / YYYY

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