Member Information/ Waiver Form *A.L.A. Cheer and Dance Academy Cheerleader/ Dancer Name:_______________________________  Age:_____ Phone Number: ________________________ Cell Phone:_________________________ E mail Address:_______________________________________  Birthdate:____________ Address:_______________________________________ Indpls., IN. Zip code:__________ Parent or Legal Guardian (sole responsible party):_________________________________ 2 Emergency Contacts: 1.Name:_____________________________ phone:_____________                                    2.Name:_____________________________ phone:_____________ List ANY and ALL medical concerns, situations or medications currently being used... __________________________________________________________________________________________________ __________________________________________________________________________________________________ ___________________________________. Doctors Name:_________________________________ Phone:________________ Currently Insured? (please circle)  Yes        No Insurance Provider:_______________________________________ Policy number:___________________________________________ *If currently uninsured or insured...Understand that there is always risk involved with All Star Cheer leading, please sign here that you understand and assume all monetary claims that may result from your child's participation in this type of activity: (Parent signature only)_______________________________  Date:____________ Medical Release and Waiver Form I (Parent, Legal Guardian)_____________________________________ will allow my child (enrollees name)_________________________________________ to participate in A.L.A. Dance and Cheer Academy (AKA : Alisha's Lil' Angels Dance and Cheer Academy).  I understand that cheer leading , gymnastics and dance is a sport that requires lifting, stunts, and rotations, as well, a physically challenging sport.  I understand fully that gymnastics and competitive style cheer leading is a dangerous sport that may cause injury, paralysis, or even death. I understand the risk that may arise from my child's participation in this activity.  I assume all responsibility for my child and understand that I am responsible for any monetary claims, actions or demands and will sign this release on behalf of my child therefore, releasing their ability to file claims in the future, and hereby waive my right of suit for any action even through negligence.  I fully release directors, coaches, assistant coaches, parent volunteers, assisting helpers and A.L.A. Dance and Cheer Academy from any injuries that may occur from this sport both ON and OFF A.L.A. Dance and Cheer Academy premises; this includes, but is not limited to Competitions, exhibitions, fun nights, camps, clinics and more. I also understand that I am fully responsible to pick my child up from practices and drop off and will not hold the organization liable for any occurrence that may result from my own negligence. I also understand that during outings away from the studio I am the responsible party for my child and agree to attend with my own child.  In the event I can not attend and my child rides and attends an event without my presence, I fully release liability to the parent volunteer, coach, director, assistant coaches and event site, in any situation I assume full responsibility at all times.  I also agree to allow my child to allow A.L.A. to photograph and that these photos may be used for promotional efforts or on our website.  By signing below I agree to ALL the terms above and agree to also allow A.L.A. to administer, call for, or release your child for medical treatment in case of emergencies, I give A.L.A. permission to make all calls regarding my child's medical treatment even without my knowledge if needed (extreme emergency), even if I don't feel that the medical attention was necessary, I assume all monetary obligations that may result in this situation as well (such as use of ambulance, etc..). Parent Printed Name:________________________________________ Date:______________ Parent Signature:____________________________________________________ Cheerleaders Name:__________________________________ 1st choice Hospital:_____________________________ 2nd choice Hospital:_____________________________ *Please print this out, fill out completely and return prior to registering your child into the program (November 25th 2007 , 6:00-8:00p.m.). Or, to LOCK in your next seasons registration send this form with your registration fee $25 (new members) to : 1 registration form required per member! Thanks! (before November use this address): Attn: Alisha/ Registration ALA Dance and Cheer Academy 6250 La Pas Trail Indianapolis, IN., 46268 (after November please use this address): Attn: Alisha/ Registration                        Registration Day takes place at this facility! ALA Dance and Cheer Academy 6263 Coffman Rd. Indianapolis, IN., 46268