Please fill out the following information.
All information will be kept confidential and on file, to be used in case of an emergency.
First Name and Last name (required)
Street Address, City and Province/State(required)
Cell phone number (required)
Your Email (required)
Personal Health Care Number (required)
Emergency Contact Name and phone number (required)
Alternate Emergency Contact and phone number
Doctor’s Name, City, and phone number(required)
Medications currently being taken (required)
Past injuries or current medical conditions which may affect your ability to train/race. Please list any other information you think would be pertinent to your overall health and safety in training or racing environment (required)
If you do not wish to appear in video or pictures on social media, notify *protected email* No problem!
For good and valuable consideration, the receipt of which is acknowledged I do hereby agree to the use of my image and/or voice without payment by Tri Balance, their subsidiaries or assigns, for use in Tri Balance training videos or other triathlon instruction or
promotional materials and, in connection therewith I, on behalf of myself, my heirs and assigns do hereby release Tri Balance, its officers, employees, agents and contractors from any and all claims or charges arising in connection with the use of my image in whole or on part, in whatever manner the company determines as part of the production of such video or other swim instruction materials or promotional materials produced in connection therewith.
I, the applicant (or legal guardian of applicant if applicant under 18 years of age), on behalf of myself, members of my family, my heirs, executors, administrators and assigns, hereby forever release discharge and hold harmless Tri Balance, its representatives and agents for any injury, loss or damage to my person or property howsoever caused, arising out of any connection with my taking part in any Tri Balance organized events and activities and notwithstanding that the same may have been contributed to or associated by the negligence of Tri Balance, its representatives or agents.
By checking this box, I agree to the above statement.