Parent/Guardian Name *

First Name

Last Name

Phone *

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Athlete 1: Name *

First Name

Last Name

Athlete 2: Name

First Name

Last Name

Athlete 3: Name

First Name

Last Name

TALENT - PARTICIPATION RELEASE *

RELEASE - CHILD I grant permission to Championship Culture Coach and its agents to use my minor child’s image (whether still, motion picture or video), recordings of my voice, and my name in association with the purpose(s) designated above. I further agree to permit editing of the production medium (digital file, video, film or audio recording) to the extent necessary for normal production purposes, provided that the intent of my performance is not altered. I understand that I/we will not be compensated for this participation.

YES

NO

WAIVER & RELEASE OF LIABILITY *

Disclaimer: Championship Culture Coach LLC, Becky Beaulieu, nor their employees, nor sub-contractors are responsible for any injury or loss of property to any person while practicing, taking class, private lesson, competing, or involved in any other way in athletic activity, mental edge lessons, or culture consultation. The parties listed above are not responsible for a loss, nor financial loss that follows culture consultation, coaching, or mental edge lessons. In consideration of my participation, I hereby release and covenant not-to-sue Championship Culture Coach LLC, Becky Beaulieu, nor its agents or sub-contractors from any and all present and future claims resulting from ordinary negligence on the part of Championship Culture Coach LLC or others listed for property damage, personal injury, or wrongful death, arising as a result of my engaging in or receiving instruction in athletic related activity, mental edge lesson, culture consultation, or any other activities incidental thereto, wherever, whenever, or however the same may occur. I herby voluntarily waive any and all claims resulting from ordinary negligence, both present and future, that may be made by me, my family, team, estate, heirs, or assigns. Further, I am aware that mental edge sessions, culture consultation, private lessons, and/or athletic activities are vigorous mental or sporting activities that pose a risk of injury. I understand that athletic related activities such as those listed above include risks, including but not limited to death, serious neck and spinal injuries resulting in complete or partial paralysis, brain damage, and serious injury to virtually all bones, joints, muscles, and internal organs. I understand that the coach and equipment provided may be inadequate to prevent serious injury. The risk of harm may be limited by all of the safety equipment and trained coaches, but never eliminated. I understand that participation in athletics and related activities involves activities incidental to active participation which may leave me vulnerable to the reckless actions of other participants who may not have complete control over their actions or who may not see the other students in the gym, court, or field. I am voluntarily participating in this activity with knowledge of the risks of property damage, personal injury, financial loss, or death. I further agree to indemnify and hold harmless Championship Culture Coach LLC and all others listed for any and all claims arising as a result of my engaging in or receiving instruction, coaching, consulting, or any activities incidental thereto, whenever, wherever, or however the same may occur. I understand that this waiver is intended to be as broad and as inclusive as permitted by the laws of the state of Wisconsin and whichever state the instruction occurred. I agree that if any portion is held invalid, the remainder of the waiver will continue in full legal force and effect. I further agree that the venue for any legal proceeding shall be within the state of Wisconsin. I affirm that I am of legal age and am freely signing this agreement. I have read this form and fully understand that by signing this form, I am giving up legal rights and or remedies which may be available to me for the ordinary negligence of Championship Culture Coach LLC, Becky Beaulieu, or any person listed above.

YES

NO

Date

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