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QCVA Waiver

Please fill out the form listed below. This waiver is required for participation at practices and competitions. This form must be filled out each year. This releases QCVA from any liabilities resulting during any club event or practice and also details procedures for any possible damage to equipment. Once completed, the listed athlete is cleared to practice and compete at QCVA events.

Athlete Above or Under the Age of 18 *

Athlete Above Age 18

Athlete Under Age 18

Athlete First Name

Athlete Last Name

Athlete DOB

High School Graduation Year

Athlete School

Select Main Event

Pole Vault

Long/ Triple Jump

Shot Put

PR (Feet)

PR (Inches)

Street Address

Street Address Line 2

City

State

Postal / Zip code

Athlete Phone

Athlete Email

Shirt Size

Jersey Size

I certify that this form is being completed by one of the the emergency contacts listed below

Emergency Contact 1 Full Name

Emergency Contact 1 Phone Number

Emergency Contact 1 Email

Emergency Contact 1 Relation

Address the same as Athelte *

Yes

Emergency Contact 1 Street Address

Street Address Line 2

City

State

Postal / Zip code

Emergency Contact 2 Full Name

Emergency Contact 2 Phone Number

Emergency Contact 2 Email

Emergency Contact 2 Relation

Address the same as Athelte *

Yes

Address the same as Emergency Contact 1 *

Yes

Emergency Contact 2 Street Address

Street Address Line 2

City

State

Postal / Zip code

By Checking this box and signing below I, the legal guardian of the athlete, verify that I have read and agree to the release and consent information.View Release and Consent Information

By Checking this box and signing below I, the above age 18 athlete listed above, verify that I have read and agree to the release and consent information.View Release and Consent Information

Effective Year

Your Signature

Thanks for submitting! You/ your athlete are cleared to participate in QCVA activities for the 2024 Season

Queen City Vault Academy

Contact

dangeljd91@yahoo.com

513 235 9724

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