Participant’s name _________________________

Street Address___________________ City ________________ Zip__________________

Allergies: _______________________

Other Medical Conditions: _______________________________________________

Participant’s Physician: _______________________________________


Father’s name _____________________________ Home phone __________________

Mother’s name _____________________________ Home phone __________________

In an emergency when parent/guardian cannot be reached or is not applicable, please contact the following:

Name ________________________ Phone ________________________

Name _______________________ Phone ___________________________

Recognizing the possibility of injury or illness, and in consideration for The Hero Within You Network Inc., accepting your child in its programs, I consent to my child participating in the programs. Further, I hereby release, discharge, and otherwise indemnify The Hero Within You Network, its member organizations and sponsors, their employees, against any claim by or on behalf of my child as a result of my child’s participation in the Programs.

I hereby represent that my child has received physical examination by a licensed medical practitioner and he/she is fit to participate in the activities of the organization. I have provided written notice, which is submitted in conjunction with this release and attached hereto, setting forth any specific issue, condition, or ailment, in addition to what is specified above, that my child has or that may impact my child’s participation in the Programs.

I give my consent to a licensed medical doctor or dentist provide my son/daughter with medical assistance and/or treatment and agree to be financially responsible for the reasonable cost of any such assistance and/or treatment.

I hereby represent that I have read and understood the terms and provisions herein and agree to be bound by them.

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