Iroquois Summer Shootout Camp

July 31 – August 3rd, Monday –Thursday

8:00 am- 11:00 pm

Return form to Iroquois HS, 211 Girdle Rd, Elma NY 14059

Player’s Name ______

T-Shirt Size:______

Grade of player starting September 2017: ______

Years of field hockey experience: ______

Health History

Allergies/medical issues (if any)

Personal Information

Address

Parent/Guardian Name:

Parent/Guardian phone number: ______

Daytime phone number (if different from above) ______

Cell Phone #: ______

Emergency Contact Name : ______

Phone number: ______

Field Hockey

Release and Waiver of Liability Form

In consideration of being permitted to participate in the IROQUOIS FIELD HOCKEY program, the undersigned acknowledges, understands, and agrees to the following:

  1. I certify that I understand the nature of IROQUOIS FIELD HOCKEY program and that I am qualified, in good health, and in the proper physical condition to participate in the program. I further agree and warrant that if at any time I believe conditions to be unsafe, I will immediately discontinue further participation in the program.
  1. I certify that I understand there are inherent risks in participating in field hockey, including risks of serious bodily injury, and I knowingly and voluntarily assume all such risks and all responsibility for losses, costs, and damages incurred as a result of my participation in the program.
  1. I hereby forever release and hold harmless IROQUOIS FIELD HOCKEY, its managers, members, coaches, employees, volunteers, representatives or agents, from any claims for damages, injuries, losses or liabilities arising in connection with my participation in the IROQUOIS FIELD HOCKEY program and its associated games and activities.
  1. I will comply with all rules and regulations of FIELD HOCKEY from time to time in effect.
  1. I agree to indemnify and hold harmless IROQUOIS FIELD HOCKEY for each cost, expense, damage, liability and loss incurred by IROQUOIS FIELD HOCKEY relating to or resulting from my participation in IROQUOIS FIELD HOCKEY and/or my failure to follow its rules and regulations.
  1. I consent to have any medical treatment deemed necessary in the event of injury, accident, and/or illness during my participation in the program. I release IROQUOIS FIELD HOCKEY from all responsibility for such action.
  1. I grant permission to have my image or audio used for any promotional, marketing and other purposes for IROQUOIS FIELD HOCKEY.

THE UNDERSIGNED ACKNOWLEDGES THAT HE OR SHE IS A PLAYER UNDER EIGHTEEN (18) YEARS OLD, OR THE PARENT OR LEAGAL GUARDIAN OF A PLAYER UNDER EIGHTEEN (18) YEARS OLD AND THAT THEY HAVE READ THIS WAIVER AND RELEASE OF LIABILITY AND FULLY UNDERSTAND ITS TERMS, AND UNDERSTAND THAT THEY HAVE GIVEN UP SUBSTANTIAL RIGHTS AND SIGN IT KNOWINGLY AND VOLUNTARILY WITHOUT ANY INDUCEMENT OR DRESS.

PRINT NAME OF PARTICIPANTPRINT NAME OF PARENT

PARTICIPANT SIGNATUAREPARENT SIGNATURE