Revival Athletics and Wellness Release Form

    General Information

    Contact Information

    Emergency Contact

    Necessary Medical Information

    Health Insurance

    Note: If you have medical insurance, your carrier will be billed for medical charges in the case of
    illness or injury while participating in a class related activity.

    Medical Release: In the event that I cannot be reached in an emergency during the dates specified on this form, I
    hereby give my permission to the physician or dentist selected by Revival’s leadership to hospitalize, to secure
    proper treatment, and/or order an injection, anesthesia, or surgery for my son or daughter, as deemed necessary.


    Liability Release: Every activity sponsored by Revival Athletics and Wellness is carefully planned and
    adequately supervised by mature adults. However, even with the best of planning and precaution, unforeseen events
    can occur. By signing this form, the parents or guardian agree to assume and accept all risks and hazards inherent in
    class related activities. They also agree not to hold Revival Athletics and Wellness, CrossFit Simplicity or its
    employees or volunteer assistants liable for damages, losses, or injuries to the person or property undersigned. The
    parents or guardians understand that they are signing for the minor listed on this form and the signature is for both a
    medical and liability release.


    Media Release: Please document below in writing if you do not want photos of yourself to be shared on
    our ministry website or social media platforms.





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