ASC ALL SPORTS CENTER at UPPER PROVIDENCE
WAIVER & RELEASE FORM
PARTICIPANT'S NAME: ______BIRTH DATE: ______
ADDRESS: ______
CITY: ______STATE: ______ZIP CODE: ______
CONTACT NUMBERS: (Indicate; work, home or cell. Use emergency numbers & write their relationship)
(1)______(number) ______(relationship)
(1)______(number) ______(relationship)
(1)______(number) ______(relationship) (1)______(number) ______(relationship)
I hereby indicate that I am the parent and/or legal guardian of ______. I request that my child be allowed to participate in any/all activities. I am in agreement with all of the terms of this Waiver & have authority to enter this Waiver in behalf of my child, myself, & all legal parties/guardians of my child.
I acknowledge that some activities have certain dangers & that accidents may occur, & that he/she could sustain injuries, death or property damage, as a consequence thereof. I hereby knowingly & voluntarily assume all risk of injury on my child's behalf while he/she is participating in the activities. Understanding the inherent risks in participating, I represent to the best of my knowledge, my child has no medical, physical, and/or emotional health conditions which would hinder against her/him participating. I also certified that my child is physically fit, & has sufficiently trained to participate in this activity, & has not been advised otherwise.
In consideration of the request & permission to participate in any/all activity, I hereby agree on my own behalf, on behalf of my child, to release & forever discharge their heirs & executors from any and all liability for injuries, death or property damage, arising or resulting from or any other way connected with my child's participation. The term of this waiver apply to myself, my child, our heirs, executors, administrators, assigns, successors, spouse, personal representatives, agents, legatees, other parents, and/or legal guardians of my child, & all family members. I agree that this Waiver shall cover my child's participation in any/all activity, including but not limited to, practice or instructional sessions, & any activity directly taught by the coach or league representatives.
I agree to indemnify or hold Release harmless from any/all liability arising out of, whether directly or indirectly, my child's involvement or participation in Release including but not limited to attorney's fees, whether paid by Release or a carrier on behalf of Release, costs, or any liability which may arise out of my child's involvement or participation in Release.
I give participation to Release to obtain on my child's behalf in any emergency treatment. In case of sickness, accident, illness or injury Release has my express permission to secure, at my express, such medical attention as is deemed necessary in the sole descretion of Release.
I have read & understand all of the information presented to me in this document & understand the terms & agreement for payment of any team fees where applicable. Lastly, I agree to accept & abide by the rules & regulations of the programs, coaches and/or referees, & facility itself.
Parent Signature: ______Date: ______