Student Name *

First Name

Last Name

Date of Birth *

MM

DD

YYYY

Student Phone Number

This information is confidential and will only be used in case of an emergency at tournaments

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Parent/Guardian 1 Name *

First Name

Last Name

Emergency Contact Phone Number *

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Parent/Guardian 2 Name

First Name

Last Name

Emergency Contact Phone Number

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Parent Guardian 3 Name

First Name

Last Name

Emergency Contact Phone Number

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My Child's Primary Care Doctor

First Name

Last Name

Doctor's Phone Number

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Medical Release *

By entering my name below, I grant permission for Stratagem Education, its employees, and agents, to provide or arrange medical treatment and/or transportation to an evacuation site and/or medical facility for my child, identified above, during an emergency or disaster.

First Name

Last Name

Contact Release *

By entering my name below, I grant permission for my child to be released to the emergency contacts whom I have specified above if I am unable to pick my child up in an emergency.

First Name

Last Name

Photographic Release *

By entering my name below, I affirm my understanding that while participating in this activity, my student may be photographed. I grant conditional permission for Stratagem Learning to use my student's photo,video, or film likeness to be used for any legitimate marketing, advertising, or other purpose. I also understand that I can revoke this permission at any time by sending Stratagem Learning a written notice, by email or post.

First Name

Last Name

Liability Waver *

By entering my name below, I HEREBY ASSUME ALL OF THE RISKS OF MY STUDENT'S PARTICIPATION IN ANY/ALL ACTIVITIES ASSOCIATED WITH THIS EVENT, including by way of example and not limitation, any risks that may arise from negligence or carelessness on the part of the persons or entities being released, from dangerous or defective equipment or property owned, maintained, or controlled by them, or because of their possible liability without fault. I certify that my student is physically fit, has sufficiently prepared or trained for participation in this activity, and has not been advised to not participate by a qualified medical professional. I certify that there are no health-related reasons or problems which preclude my student's participation in this activity, and that all relevant medical conditions,allergies, and physical impediments have been disclosed in writing to Ben Fagan and Stratagem Learning prior to my student's participation.I further acknowledge that this Accident Waiver and Release of Liability Form will be used by the event holders,sponsors, and organizers of the activity in which my student may participate, and that it will govern my student's actions and responsibilities at said activity, though additional tournament specific waivers may need to be submitted for specific events.In consideration of my application and permitting my student to participate in this activity, I hereby take action for myself, my executors, administrators, heirs, next of kin, successors, and assigns as follows:(A) I WAIVE, RELEASE, AND DISCHARGE from any and all liability, including but not limited to, liability arising from the negligence or fault of the entities or persons released, for my student's death, disability, personal injury, property damage, property theft, or actions of any kind which may hereafter occur to my student including traveling to and from this activity, THE FOLLOWING ENTITIES OR PERSONS: Ben Fagan, Stratagem Learning and/or their directors, officers, employees, volunteers, representatives, and agents, and the activity holders,sponsors, and volunteers;(B) INDEMNIFY, HOLD HARMLESS, AND PROMISE NOT TO SUE the entities or persons mentioned in this paragraph from any and all liabilities or claims made as a result of participation in this activity, whether caused by the negligence of release or otherwise.I acknowledge that Ben Fagan, Stratagem Learning, and their volunteers, representatives, and agents are NOT responsible for the errors, omissions, acts, or failures to act of any party or entity conducting a specific activity on their behalf. I acknowledge the risks of this activity include, but are not limited to, those caused by terrain, facilities, temperature,weather, condition of participants, equipment, vehicular traffic, lack of hydration, and actions of other people including, but not limited to, participants, volunteers, monitors, and/or producers of the activity .I hereby consent for my student to receive medical treatment which may be deemed advisable in the event of injury, accident, and/or illness during this activity.The Accident Waiver and Release of Liability Form shall be construed broadly to provide a release and waiver to the maximum extent permissible under applicable law. I CERTIFY THAT I HAVE READ THIS DOCUMENT AND I FULLY UNDERSTAND ITS CONTENT. I RECOGNIZE THAT SELECTING "NO" WILL BAR MY STUDENT FROM PARTICIPATION IN ALL CLASSES AND OUTSIDE ACTIVITIES PROVIDED BY STRATAGEM LEARNING AND WILL NOT QUALIFY ME FOR A REFUND OF MY TUITION OR OTHER PAYMENTS. I AM AWARE THAT THIS IS A RELEASE OF LIABILITY AND A CONTRACT AND I SIGN IT OF MY OWN FREE WILL.

First Name

Last Name