ITINERARY
Thursday, October 23:
Arrival in New York City. All filmmakers and attendees will check-in and register between 12:00pm and
6:00pm, but please note, hotel rooms are not guaranteed until 3:00pm. Evening activities will include
free time and sightseeing in New York’s famous Times Square and a variety of film-related activities will
be suggested.
Friday, October 24:
For filmmakers and attendees arriving on Friday in New York City check-in and registration between
9:00am and 6:00pm, but please note, hotel rooms are not guaranteed until 3:00pm. Evening activities
will include opening night movie premiere and party – presented by Santa Fe University of Art and
Design - at the New York Hilton Midtown Grand Ballroom beginning at 8:00pm.
Don’t miss the Red Carpet
Premiere of the documentary
AMERICAN CHEERLEADER
at the Festival!
Saturday, October 25:
Throughout the day, enjoy select screenings of your choice, engage in panel discussions and visit the
technology fair and social media lounge. Our comprehensive Film and Media College Fair featuring 25+
schools will take place from 12:00pm to 2:00pm. All College Fair Attendees will receive a FREE lunch. In
the evening you will enjoy a fabulous red carpet and Awards Show presented by Cantinas Entertainment
and Dinner (included in travel package) at the New York Hilton Midtown Grand Ballroom with special
guests Keynote Speaker Doug Ellin (creator of Entourage), Pop-Star Alli Simpson, MTV Star Andrew
Jenks and many more!
Sunday, October 26:
Begin the day with “Best of the Fest” and Audience Selected screenings. This will be followed by
exclusive workshops, “Andrew Jenks and Friends: Behind the Scenes of a Hit TV Show” and
“Elevate Your Game: How to be the Next Winner of the AAHSFF.”
Filmmakers and attendees departing the hotel must check out no later than 11:00am.
Monday, October 27:
Filmmakers and attendees departing the hotel must check out no later than 11:00am.
Note: We reserve the right to alter and adjust the itinerary and/or hotel in order to accommodate
the size of the total group.
2013 Celebrity Judges: Dylan McDermott, Morgan Spurlock, Carlton Cuse, Diablo Cody,
Danny Rose, Ed Burns, Henry Winkler, Andrew Jenks, and Kristen Stewart.
Set in the competitive world
of cheerleading, AMERICAN
CHEERLEADER follows the journey
of two high school teams vying for
the coveted National High School
Cheerleading Championship Title.
Overcoming challenges through
discipline, dedication and teamwork, twelve girls from New Jersey
and twelve girls from Kentucky
redefine what it means to be an
AMERICAN CHEERLEADER.
E V E N T PA C K A G E D E TA I L S
Event Package Includes:
1.
2.
3.
4.
5.
6.
7.
8.
9.
Hotel accommodations at the New York Hilton Midtown
Hotel taxes (city, state, occupancy)
Opening Night Movie Premiere and Party - Presented by
Santa Fe University of Art and Design
Saturday Passes to:
a. Official Selection Screenings
b. Industry Insider Panel Discussions
c. Comprehensive Film and Media College Fair
(All College Fair attendees will receive a FREE lunch)
d. Technology Showcase
e. Social Media Lounge at the AMC Empire 25 Theaters in Times Square.
Exclusive one hour Red Carpet followed by Awards Show and dinner Presented by
Cantinas Entertainment featuring live musical performances and celebrity appearances
at the New York Hilton Midtown Grand Ballroom with special guests Keynote Speaker
Doug Ellin (creator of Entourage), Pop-Star Alli Simpson, MTV Star Andrew Jenks and
many more!
Sunday Passes to Best of the Fest and Audience Selected Screenings
Exclusive Workshops:
a. Elevate Your Game: How to be the Next Winner of the AAHSFF
b. Andrew Jenks and Friends: Behind the Scenes of a Hit TV Show
Commemorative Drawstring Bag
AAHSFF Commemorative Pin
Exclusive Travel
Package Perks
F Your Only Way Into The
Opening Night Party!
F VIP Seating with Awards
Show and dinner
F Exclusive one hour Red
Carpet photo opportunity
F Exclusive Workshops
F Chance to win $1,000’s of
dollars in prizes
F Special Sunday screening
of Relativity Studio’s Film
Optional Transportation Package:
Airport Transfers from LaGuardia airport ONLY will be offered for an additional cost of $25 per person each way ($50 round trip).
Our shuttle service will be available from 10:00am to 4:00pm on Thursday October 23rd and Friday October 24th. If you are traveling
by train to New York, you will be responsible for your transportation to the hotel. Return times will be based on flight information provided.
Optional Meal Packages:
Meals will be provided in the event package for lunch if you attend the College Fair on Saturday at the AMC Empire
25 Theaters and dinner for the Saturday night Awards Show. You may also purchase a meal package with various local restaurants
(McDonald’s, Sbarro, Europa / Pax Foods) for an additional cost.
We recommend the below meal package options:
• $28 One Night Meal Package – includes 1 breakfast and 1 lunch voucher.
• $54 Two Night Meal Package – includes 2 breakfasts, 1 lunch and 1 dinner voucher.
• $78 Three Night Meal Package – includes 3 breakfasts, 1 lunch and 2 dinner vouchers.
• $103 Four Night Meal Package – includes 4 breakfasts, 2 lunches and 2 dinner vouchers.
What the Package does not include:
1. Transportation to New York including but not limited to plane, train and/or automobile
2. All personal items and clothing.
2 0 1 4 E V E N T PA C K A G E S A N D P R I C I N G
We require one chaperone per 5 student participants. Chaperones must be 21 years or older.
FOUR NIGHTS:
Travel package price for the four nights of October 23 (check-in)
through October 27 (check-out) includes:
• Four nights and five days hotel accommodations
• Exclusive Event Workshops
• Tickets to the Opening Night Party and Movie Premiere,
• Tickets to Official Selection Screenings, College Fair, Tech Fair,
Panel Discussions and Social Media Lounge at AMC Theater
• Red Carpet and Awards Night presentations at the
New York Hilton Midtown Hotel Grand Ballroom
• Commemorative Pin and drawstring backpack
• All taxes and gratuities
• All registration fees for the Festival
Quad (4 per room)
Triple (3 per room) Double (2 per room) Single (1 per room) $720.70 per person
$840.70 per person
$1080.70 per person
$1800.70 per person
TWO NIGHTS:
The travel package price for the two nights of October 24
(check-in) through October 26 (check-out) includes:
• Two nights and three days hotel accommodations
• Exclusive Event Workshop
• Tickets to the Opening Night Party and Movie Premiere,
• Tickets to Official Selection Screenings, College Fair, Tech Fair,
Panel Discussions and Social Media Lounge at AMC Theater
• Red Carpet and Awards Night presentations at the
New York Hilton Midtown Hotel Grand Ballroom
• Commemorative Pin and drawstring backpack
• All taxes and gratuities
• All registration fees for the Festival
Quad (4 per room)
Triple (3 per room)
Double (2 per room) Single (1 per room) $490.70 per person
$550.70 per person
$670.70 per person
$1030.70 per person
(NONE OF THE ABOVE PRICES INCLUDE AIRFARE OR TRANSPORTATION.)
* Most rooms will have two double beds, however double and single rooms
may have only one king bed.
(NONE OF THE ABOVE PRICES INCLUDE AIRFARE OR TRANSPORTATION.)
* Most rooms will have two double beds, however double and single rooms
may have only one king bed.
THREE NIGHTS:
ONE NIGHT:
The travel package price for the three nights of October 24
(check-in) through October 27 (check-out) includes:
• Three nights and four days hotel accommodations
• Exclusive Event Workshops
• Tickets to the Opening Night Party and Movie Premiere,
• Tickets to Official Selection Screenings, College Fair, Tech Fair,
Panel Discussions and Social Media Lounge at AMC Theater
• Red Carpet and Awards Night presentations at the
New York Hilton Midtown Hotel Grand Ballroom
• Commemorative Pin and drawstring backpack
• All taxes and gratuities
• All registration fees for the Festival
Quad (4 per room)
Triple (3 per room) Double (2 per room)
Single (1 per room) $605.00 per person
$695.00 per person
$875.00 per person
$1415.70 per person
The travel package price for the one night of October 25 (checkin) through October 26 (check-out) includes:
• One night and two days hotel accommodations
• Exclusive Event Workshop
• Tickets to the Opening Night Party and Movie Premiere,
• Tickets to Official Selection Screenings, College Fair, Tech Fair,
Panel Discussions and Social Media Lounge at AMC Theater
• Red Carpet and Awards Night presentations at the
New York Hilton Midtown Hotel Grand Ballroom
• Commemorative Pin and drawstring backpack
• All taxes and gratuities
• All registration fees for the Festival
Quad (4 per room)
$350.70 per person
Triple (3 per room)
$380.70 per person
Double (2 per room) $440.70 per person
Single (1 per room) $620.70 per person
(NONE OF THE ABOVE PRICES INCLUDE AIRFARE OR TRANSPORTATION.)
* Most rooms will have two double beds, however double and single rooms
may have only one king bed.
(NONE OF THE ABOVE PRICES INCLUDE AIRFARE OR TRANSPORTATION.)
* Most rooms will have two double beds, however double and single rooms
may have only one king bed.
COMMUTER PARTICPANT: $250
EXTRA NIGHTS:
For those participants who live within 85 miles and not purchasing the
travel package, there is a $250 per participant commuter registration.
This fee includes:
• Exclusive Event Workshops
• Tickets to the Opening Night Party and Movie Premiere,
• Tickets to Official Selection Screenings, College Fair, Tech Fair,
Panel Discussions and Social Media Lounge at AMC Theater
• Red Carpet and Awards Night presentations at the
New York Hilton Midtown Hotel Grand Ballroom
• Commemorative Pin and drawstring backpack
• All taxes and gratuities
• All registration fees for the Festival
(ONLY WITH THE FOUR NIGHT TRAVEL PACKAGE!)
You may add an extra night on Monday Oct. 27, 2014
Since the hotel has very limited space available for this night,
reservations for the extra night will be accepted on a first come-first
served basis.
All rooms . . . . . . . . .$399.00 per room (regardless of occupancy)
See Extra Ticket Form to buy individual tickets,
meal packages and optional transportation
For Updates and Information go to www.HSFilmFest.com
Contact our Registration Specialist
Contact – Lakeishia Kearney at [email protected]
Toll Free: 800-381-0038 • Fax: 800-969-8295
2014 VARSITY BRANDS ALL AMERICAN
HIGH SCHOOL FILM FESTIVAL
PARTICIPANT REGISTRATION FORM
Participant name: ________________________________________________________________________________________________________________________________________________
Full address: ____________________________________________________________________________________________________________________________________________________
Street Address (no P.O. Boxes accepted)
City
State
Zip
Home number: (_______)_____________________ Cell number: (_______)_____________________ Email address: _______________________________________________________________
Year in school Fall of 2014: ________________________
Name of your school: ________________________________________________ School address/city/state: _____________________________________________________________________
Parent Contact: ___________________________________________________________ Parent Email address: ____________________________________________________________________
Parent Contact: Work Phone: (____)___________________ Home Phone: (____)_____________________ Cell Phone: (____)________________________________________________________
Participant Chaperone: ___________________________________________________________________________________________________________________________________________
(attending the event)
TRAVEL INSURANCE: I PLAN TO:
 Purchase travel insurance via the internet (www.insuremytrip.com)  Get my own travel insurance
 Not have any travel protection
(If you are a commuter please write “commuter” in the rooming list area)
EXTRA NIGHTS at $399 per room per night: # of rooms________for Monday, Oct. 27
ROOMING ASSIGNMENTS (AAHSFF does not assign roommates)
TOTAL ADULTS:_________ TOTAL MINORS:_________ (If you have not purchased this package, you may not room with a participant)
ROOMING LISTS (IMPORTANT): This form must be filled out completely in order for your registration to be accepted. Reservation will be entered according to the dates below and
charged as such. List below names in full of people staying in either quad (4), triple (3), double (2) or rooms. In parenthesis, specify on of the following for each person: (P)=Participant
(A)=Advisor
(F)=Family/Friend
Please Note: Rollaway beds are not available.
(PLEASE PRINT OR TYPE)
Please list any food allergies or dietary needs_____________________________________________________________________________________________________
MODE OF TRANSPORTATION TO NEW YORK
DOUBLES (TWO IN EACH ROOM)
P/A/F
Flying
Driving
DOUBLES (TWO IN EACH ROOM)
ARRIVAL DATE DEPART DATE
P/A/F
ARRIVAL DATE DEPART DATE
1._________________________________(_____)____(_____)____(_____)
1._________________________________(_____)____(_____)____(_____)
2._________________________________(_____)____(_____)____(_____)
2._________________________________(_____)____(_____)____(_____)
1._________________________________(_____)____(_____)____(_____)
1._________________________________(_____)____(_____)____(_____)
2._________________________________(_____)____(_____)____(_____)
2._________________________________(_____)____(_____)____(_____)
TRIPLES (THREE IN EACH ROOM)
QUADS (FOUR IN EACH ROOM)
P/A/F
ARRIVAL DATE DEPART DATE
P/A/F
ARRIVAL DATE DEPART DATE
1._________________________________(_____)____(_____)____(_____)
1._________________________________(_____)____(_____)____(_____)
2._________________________________(_____)____(_____)____(_____)
2._________________________________(_____)____(_____)____(_____)
3._________________________________(_____)____(_____)____(_____)
3._________________________________(_____)____(_____)____(_____)
4._________________________________(_____)____(_____)____(_____)
PLEASE RE-READ THE PAYMENT SCHEDULE, CANCELLATION AND REFUND SECTIONS BEFORE SIGNING THIS CONTRACT.
I/WE HAVE READ THIS BROCHURE AND UNDERSTAND AND ACCEPT ITS CONTENTS:
________________________________________
Participant’s Signature
____/____/____
Date
(_____)_______________
Daytime Phone
________________________________________
Guardian/Parent Signature
____/____/____
Date
(_____)_______________
Daytime Phone
CANCELLATIONS AND REFUNDS:
For cancellations received BEFORE September 12, 2014, all monies will be refunded with the exception of the $200.00 per person deposit. For cancellations made BETWEEN
September 12, 2014 and October 10, 2014, an additional $100.00 per person penalty will apply to cover entertainment guarantees. For cancellations received AFTER October 10, 2014,
THERE WILL BE NO REFUNDS.
All cancellations must be in writing. WE WILL NOT ACCEPT CANCELLATIONS BY PHONE. Cancellations may be faxed to 800-969-8295 Attn: AAHSFF.
EXTRA TICKET FORM
This form and full payment are due in the
Varsity Brands All American
High School Film Festival
Registration Office by September 3, 2014.
Credit Card orders may be faxed to:
1-800-969-8295 or 1-901-387-4357
If confirmation is not received within 2 weeks,
verfication should be directed to
[email protected].
Checks and forms are to be mailed to:
Varsity Brands All American High School
Film Festival - Ticket Orders
P.O. Box 752790
Memphis, TN 38175-2790
No extra ticket orders will be
accepted after September 25, 2014.
After the deadline, tickets may
be purchased in New York
at the Hotel. (limited available)
____________________________________________________________________________________________
School Name City State
____________________________________________________________________________________________
Name (NOTE: Only the person listed here will be able to sign for and pick up ALL tickets in New York!)
____________________________________________________________________________________________
Address
(____________________________________________________________________________________________
)
(
)
(
)
Home Phone Work Phone Cell Phone
____________________________________________________________________________________________
Email Address
ADDITIONAL PACKAGE OPTIONS
INDIVIDUAL TICKETS (These tickets are for anyone not on the package)
*Saturday AMC Theater Pass – $50.00 each Number Needed___________
(Does Not Include: Opening Night, Awards Show or Sunday Activities)
*General Admission Saturday Awards Show Ticket – $50.00 each Number Needed___________
(Red Carpet and dinner NOT included)
*VIP Saturday Awards Show Ticket – $150.00 each Number Needed___________
(Red Carpet and dinner included)
TRANSPORTATION
From New York LaGuardia Airport – $25.00 each Number of Passengers _________
To New York LaGuardia Airport – $25.00 each Number of Passengers _________
MEAL VOUCHERS
One Night Meal Package – $28.00 each
Number Needed___________
Two Night Meal Package – $54.00 each
Number Needed___________
(Includes 1 breakfast and 1 lunch voucher)
(Includes 2 breakfasts, 1 lunch and 1 dinner voucher)
Three Night Meal Package – $78.00 each
Number Needed___________
(Includes 3 breakfasts, 1 lunch and 2 dinner vouchers)
Four Night Meal Package – $103.00 each
(Includes 4 breakfasts, 2 lunches and 2 dinner vouchers)
Number Needed___________
Note: Meal packages are recommended options. You do not have to do the same meal voucher options as the travel package.
* Tickets can be picked up in New York at the hotel registration area Thursday, October 23rd or Friday, October 24th.
On Saturday, October 25th, tickets can be picked up at the AMC Theater Information Table. If you are NOT staying on
the Travel Package please pick up your tickets at the New York Hilton Midtown Registration Area.
METHOD OF PAYMENT: Enclosed is check number __________ for $ ____________
I authorize the Varsity Brands All American High School Film Festival to charge my
VISA MC AMEX DISC in the amount of $_________ for tickets.
(Please complete the attached Credit Card form to complete order.)
• • • YOU MAY MAKE COPIES OF THIS FORM • • •
CREDIT CARD PAYMENTS FOR DEPOSIT
If anyone would like to charge their deposit on a credit card, we accept VISA, MasterCard, American Express or Discover. Below list
the person wishing to charge, their credit card number, expiration date and amount to be charged along with their signature.
*WE MUST HAVE YOUR FULL BILLING ADDRESS IN ORDER TO PROCESS A CHARGE.
____________________________________________________________________________________________________________________________________________
Card Holder Name
____________________________________________________________________________________________________________________________________________
Address (city, state, zip)
____________________________________________________________________________________________________________________________________________
Team/School Name
____________________________________________________________________________________________________________________________________________
Team/School Address (city/state/zip)
 VISA  MC  AMEX  DIS
Card #
Exp. Date _____ /_____ /_____
oooo oooo oooo oooo
Amount Charged _______________________________________
o Deposit
o Full payment
Signature ___________________________________________________________________________________________________________________________________
Daytime or Cell Phone # (_______)_______________________________________________________________________________________________________________
Email _______________________________________________________________________________________________________________________________________
VARSITY BRANDS ALL AMERICAN HIGH SCHOOL FILM FESTIVAL
RULES OF CONDUCT AND BEHAVIOR
There will be many girls, boys, parents, and staff traveling to New York as part of this event. We are looking forward to a great event, and would like to take this opportunity to assure all parents
that our main concern is each participant’s safety. Therefore, we have established the following rules of conduct and behavior for each participant while on tour. Varsity Spirit and AAHSFF,
asks each participant and their parents to carefully read and understand the necessity of following these rules. Parents and participants must both sign this form and return it (with registration
and other attached forms) to the Varsity office. Please remember that we want you to have a great time, but within the parameters of this agreement.
1. A chaperone/adult (age 21 and over) is required to attend with participants. This chaperone will be responsible for participants outside of scheduled events (free time) including but not
limited to free time at event site or hotel.
2. Festival is not responsible for participants on their free time.
3. I understand that during the independent or free time on this tour, I will be able to sightsee or shop with my chaperone.
4. It is strictly PROHIBITED to all any member of the opposite sex in my room, whether or not they are a member of the tour and to do so will result in immediate expulsion from the tour.
I also understand that if any strangers are found in my room, they will immediately be expelled from the hotel by hotel security, and the Varsity staff.
5. The use of alcohol and/or any other controlled substance is strictly PROHIBITED AND FORBIDDEN. No smoking is allowed. Failure to comply will result in immediate dismissal
and a letter to your principal.
6. I will be expected to be on time for all events.
I understand and agree that any infraction of these rules and conditions could cause my immediate expulsion from the tour and result
in my being sent home at my parent’s expense without refund for unused portions of the trip.
________________________________________________________
Participant’s Signature
________________________________________________________
Date
________________________________________________________
Parent’s Signature
________________________________________________________
Date
To be completed and returned for participants only.
RETURN TO:
Varsity Brands All American High School Film Festival
P.O. Box 752790
Memphis, TN 38175-2790
IF YOU FAIL TO COMPLETE ANY PART OF THIS FORM, IT WILL BE RETURNED TO YOU FOR COMPLETION, PRIOR TO ACCEPTANCE.
SCHOOL NAME: _______________________________________
VARSITY BRANDS ALL AMERICAN HIGH SCHOOL FILM FESTIVAL RELEASE/WAIVER FORM | OCTOBER 23-27, 2014
LIABILITY RELEASE. For good and valuable consideration, the receipt and sufficiency of which are hereby acknowledged, I _________________________________, as parent
or legal guardian of ___________________________________________, a minor (hereinafter “Minor”, hereby grant the permission necessary to allow this minor to participate in the
above Event to be conducted by Varsity Spirit Corporation (”Varsity Spirit”) and All American High School Film Festival (“AAHSFF”). I, in my own behalf and on behalf of the Minor, further
agree to release and to hold harmless Varsity Spirit, Varsity Spirit’s Corporate Sponsors (hereinafter “Sponsors”) and AAHSFF, the Hosting site, (hotel, parade organizations and other entity
providing service whilst on this Event and on whose premises the Event will occur (hereinafter the “Location”) the affiliates of Varsity Spirit, AAHSFF and the Location, and the respective directors, officers, representatives, members, agents and employees of Varsity Spirit, Sponsors, and AAHSFF, the Location and their respective affiliates (hereinafter collectively “Releases”) from
any and all liability for negligence or any other claim judgement, loss, liability, cost and expenses (including, without limitations, attorney’s fees and costs) arising out of or connected with the
Event, including any claim arising out of or connected with any illness or injury (minimal, serious, catastrophic and/or death) that the Minor may incur or sustain during the Event, all activities
associated with the Event and while traveling to and from the site for the Event whether or not the Event actually occurs. I further expressly agree to indemnify and hold harmless Releases
and Releasees’ heirs, successors, assigns, executors and administrators against loss from any further claims, demands or actions that may subsequently be brought by Minor or by any other
persons on the account of damages of any character resulting to Minor in any way from the foregoing activities. I further agree to reimburse and to make good to Releasees any loss, or costs
Releasees may have to pay as a result of any such action, claim, or demand.
I, in my own behalf and on behalf of the Minor, hereby warrant that I have read this Liability Release in its entirety and fully understand its contents. I, in my own behalf and on behalf of the
Minor, am aware that this Liability Release releases Releasees from liability and contains an acknowledgement of my voluntary and knowing assumption of the risk of injury or illness. I, in my
own behalf and on behalf of the Minor, further acknowledge that nothing in this Liability Release constitutes a guarantee that the Event will occur. I, in my own behalf and on behalf of the
Minor, have signed this document voluntarily and of my own free will.
Signature of Parent of Legal Guardian X_________________________________________________________________________________
Date:____ /____ /_____
MEDICAL RELEASE. I, in my own behalf and on behalf of the Minor, acknowledge and agree that such participation subjects Minor to possibility of physical illness or injury (minimal,
serious, catastrophic, and/or death) and that I, in my own behalf and on behalf of the Minor, acknowledge that the Minor is assuming the risk of such illness or injury by participating in the
Event. In the event of such illness or injury, I authorize Varsity Spirit and AAHSFF to obtain necessary medical treatment of the Minor and hereby, in my own behalf and on behalf of the Minor,
release and hold harmless Releasees in the exercises of this authority. I further acknowledge and understand that I will be responsible for any and all medical and related bills that may be
incurred on behalf of the Minor for any illness or injury that the Minor may sustain during the Event and while traveling to and from the site for the Event whether of nor the Event actually occurs.
APPEARANCE AGREEMENT. I understand that Varsity Spirit and AAHSFF from time to time produce promotional material relating to their programs. I understand that as a participant
and/or a spectator at the Event that Minor may be included in videotapes, photographs, DVD’s, Podcasts, and videocasts taken during the Event. Therefore, without reservation or limitations,
I, in my own behalf and on behalf of the Minor, hereby assign, transfer and grant to Varsity Spirit and AAHSFF, their successors, assignees, licensees, sponsors, and television networks, and
all other commercial exhibitors the exclusive right to photograph and/or videotape the Minor and to utilize such videotapes and photographs and Minor’s name, face, likeness, voice and
appearance as a part of the Event, in advertising and promoting the Event or in advertising and promoting similar future events. I further understand that neither Varsity Spirit and AAHSFF nor
any third party is under any obligation to exercise any of the foregoing rights, licenses and privileges.
EVENT RULES. I further acknowledge and understand that Varsity Spirit and AAHSFF have established rules and regulations pertaining to conduct behavior and activities of all Event
participants, by which Minor and I agree to abide during the Event. Minor and I have signed a copy of these rules and regulations and will be responsible for his/her/my failure to abide by
those rules and regulations. Minor and I have received, read and understand the Event rules. Minor and I understand that violation of the rules can result in dismissal from Event with no refund.
INSURANCE
Insurance Company: ___________________________________________________________________________________________________________________
Insurance Company Address: ____________________________________________________________________________________________________________
Medical Insurance Policy Number: ________________________________________________________________________________________________________
I represent that any medication to which Minor is allergic or medications that Minor is currently taking are listed below. I agree that Minor shall bring medications which Minor is currently
taking with him/her to the Event and that he/she shall consume the prescribed dosage for such medications.
Medications (if any): __________________________________________________________________________________________________________________________
Allergic to (if any): ____________________________________________________________________________________________________________________________
I acknowledge that the Minor suffers from the following conditions: ____________________________________________________________________________________
____________________________________________________________________________________________________________________________________________
Family Doctor: ______________________________________________________ Phone Number: (_______)_________________________________________________
EMERGENCY INFORMATION
Name: ___________________________________________________________________________________
Address: __________________________________________________________________________________
City, State, Zip: ____________________________________________________________________________
Daytime phone: (____)____________ Evening phone: (____)____________ Cell phone: (____)____________
I, in my own behalf and on behalf of the Minor, herby warrant that I have read this Release/Waiver Form in its entirety and fully understand its concerns. I, in my own behalf and on behalf
of the Minor, am aware that this Release/Waiver Form releases Releasees from liability and contains an acknowledgement of my voluntary and knowing assumption of the risk of injury or
illness. I, in my own behalf and on behalf of the Minor, further acknowledge that nothing in this Release/Waiver Form constitutes a guarantee that the Event will occur. I, in my own behalf
and on behalf of the Minor, have signed this document voluntarily and of my own free will.
Signature of Parent of Legal Guardian X________________________________________________________
Relationship to Minor: _______________________________________________________________________
Minor SS# __________-__________-__________
Minor Birthdate: ____/____/____
I, identified above as Minor, acknowledge that I have read this Release and Waiver Form.
Signature of Minor X___________________________________________________ Date:____/____/_____
Signature of Witness X__________________________________________________ Date:____/____/____
Witness Address: ___________________________________________________________________________