RELEASE OF LIABILITY
Name____________________________________________
Address__________________________________________
City _______________________State _____
ZIP ________
Email: _______________________________________
Home Phone: _____-_____-_________
Grade (Fall 12) ______ Gender ______
Emergency Contact:
_________________________________________________
Emergency Phone:
_____-_____-________
Site Location:_________________________
Site Time:____________________________
Release of Liability
I hereby waive and release for myself and my heirs, any and all rights or claims I may have against the Performance Course, Inc. (PCI), any affiliates or subdivisions of Performance Course, Inc., any school of facility in which Performance Course, Inc are conducted, and each of their respective agents, employees, servants, officers, directors, and representatives, for injury or illness airing out of or in any way connected with my participation in the Performance Course, Inc. I further agree to indemnify and hold harmless of each said persons or property which may arise by virtue of my participation in the Performance Course, Inc. I understand there are certain risks and dangers associated with all activity involved in the Performance Course, Inc and the use of the facility. Injuries can and do occur during Performance Course, Inc. I hereby grant permission for trainers, doctors and their designees to administer appropriate medical care, antigens or injuries, and to perform emergency procedures as necessary.
Participant, agrees to waive any claim against PCI for ANY DAMAGE, LOSS, COST, EXPENSE OR LIABILITY RESULTING FROM PERFORMING (OR FAILING TO PERFORM) ANY DUTIES OR FUNCTIONS, AND PCI IS HEREBY RELEASED FROM LIABILITY TO THE PARTICIPANT OR HIS PARENTS FOR ANY AND ALL DAMAGES, LOSSES, COSTS, EXPENSES AND LIABILITIES ARISING OUT OF ANY INCIDENT TO OR RESULTING FROM SUCH PERFORMANCE OR FAILURE TO PERFORM, EVEN THOUGH CAUSED IN WHOLE OR IN PART BY THE NEGLIGENCE (WHETHER BY ACT OF OMISSION OR COMISSION), GROSS NEGLIGENCE, STRICT LIABILITY OR OTHER LEGAL FAULT OF PCI.
Secondary Insurance
Performance Course, Inc., (PCI) provides student insurance coverage free of charge for all of our students who are involved in PCI. This coverage is secondary to any coverage that you may have. You must file on your primary policy first, pay any deductible and then the Performance Course, Inc policy second. Once your primary insurance has been paid, then the remaining expenses, up to the maximum benefits allowed, will be paid by the secondary policy. If you do not have primary insurance coverage, the PCI insurance will only pay the maximum benefits allowed. There is no guarantee that all medical expenses will be covered. You are responsible for any remaining expenses left uncovered or unpaid.
Video/Photo Release
I hereby give permission for images of the participant, captured during the Performance Course, Inc (PCI) program listed through video, photo and digital camera, to be used solely for the purposes of PCI promotional material and publications, and waive any rights of compensation or ownership thereto.
Signing the guardian signature states that you understand and agree to the terms of the Release of Liability, Secondary Insurance and Video/Photo Release.
Guardian Signature _____________________________________
Date_____________
NO REFUNDS
