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NC HEAT TRYOUTS AND CAMPS 2017

PLAYER INFORMATION

* First Name:

* Last Name:

Street:

City:

State:

Zip Code:

Home Phone:

* Birthdate:

Email:

Gender:

* Grade:

PARENT/GUARDIAN #1

Firstname:

Lastname:

EMail:

Home Phone:

Work Phone:

Cell Phone:

PARENT/GUARDIAN #2

Firstname:

Lastname:

Email:

Home Phone:

Work Phone:

Cell Phone:

MEDICAL/EMERGENCY CONTACT INFORMATION

Emergency Contact:

Phone:

* Relationship to Player:

Insurance Carrier:

Policy #:

WAIVERLIABILITY WAIVER AND RELEASE:
I hereby release and discharge NC HEAT, its staff, officers, employees, agents, sponsors, and affiliated entities from any and all liability or causes of action rising out of, or in connection with, my child participation in the program, including, but not limited to any and all liability or causes of action arising out of, or in connection with any negligence of, or any acts or omissions of, NC HEAT, its staff, officers, employees, agents, sponsors, and affiliated entities.
I hereby authorize NC HEAT and its staff to act on behalf of my child according to its best judgment in any emergency requiring medical attention including in relation to obtaining any medical of hospital treatment.
I herby release and discharge NC HEAT, its staff, officers, employees, agents, sponsors, and affiliated entities from any and all liability or causes of action arising out of, or in connection with, any such actions by NC HEAT in any emergency requiring medical attention, including but not limited to any and all liability or causes of action arising out of, or in connection with, any negligence of, or any acts of omissions of NC HEAT, its staff, officers, employees, agents, sponsors, and affiliated entities.
I have read and reviewed this REGISTRATION FORM, including the ACKNOWLEDGEMENT AND RELEASE and the LIABILITY WAIVER AND RELEASE and I have had the opportunity to ask any questions that I might have regarding the same. I expressly agree to the terms and provisions of this REGISTRATION FORM, including the ACKNOWLEDGEMENY AND RELEASE and the LIABILITY WAIVER AND RELEASE above.
______________________________________ _________________________
Parent signature Date
INFORMATION

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NC HEAT TRYOUTS AND CAMPS 2017