PROVISION ON MEDICAL RELEASE AND

ADEQUATE INSURANCE COVERAGE

By initialing below, I certify that I have adequate insurance to cover any injury or damage that I may cause or suffer while participating, or else agree to bear the costs of such injury or damage myself.

Initials (to certify the above):

Full Name:

Medical Insurance Carrier:

Name of Medical Physician:

Policy/Program #:

Insurance Co Phone #:

Medical Physician Phone #:

I authorize Cheer Honolulu or any of its coaches, captains, managers, Board of Directors, employees, volunteers, contractors, or agents to make decisions regarding medical care in case of emergency. I agree to pay all costs associated with such care and related transportation.

Signature Required