Revival Athletics and Wellness Release Form

General Information

Name:

DOB:

Age:

Name of Parents/ Guardian if under 18:

Address:

Contact Information

Cell Phone:

Email:

Receive News Letter emails:
YesNo

Receive notification of class schedule changes/cancellations:
YesNo

Emergency Contact

Name:

Phone:

Necessary Medical Information

Allergies:

Relevant Medical History:

Any Activity Restrictions:
NoYes

If Activity Restrictions please explain:

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.

Do you have health insurance?:
NoYes

Name of Insurance Provider:

Policy Number:

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.

Media Release Decline:

I have read and understand the medical release, liability release and media release.

Enter your full name to digitally sign:

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