San Diego Cougars P.R.E.P./The Hive

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San Dieo Cougars PREP Wavier

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 #:

WAIVER INFORMATION

RELEASE/WAIVER FOR SAN DIEGO COUGARS/TEAM PREPS /Educated Hoops YOUTH (MINORS)

I, the undersigned parent/person having legal custody/guardianship of the above said
minor, give permission for the minor to participate in all Educated Hoops/San Diego Cougars/Team PREP programs. The minor is physically
able and mentally prepared to participate in all activities as described in the announcement for the program.

In consideration of said minor being permitted to enter any gyms for observation, use of facilities and/or equipment,
above or any program, I, on behalf of myself (as parent, guardian, coach aide, spectator or
participant) hereby:

1. Acknowledge that (i) I have read this document, (ii) I have inspected the Educated Hoops/San Diego Cougars/Team PREP facilities
and equipment, (iii) I accept them as being safe and reasonably suited for the purposes
intended, and (iv) I voluntarily sign this document.

2. Release San Diego Cougars/Team PREP/Educated Hoops/Steel Canyon,Jackie Robinson YMCA, Crawford its directors, officers, employees, and volunteers (collectively
“Releasees”) from all liability to me for any loss or damage to property or injury or death to
person, whether caused by Releasees or otherwise and while such minor is in or near any Hoop San Diego Cougars/Team PREP practices or games.

3. I agree not to sue Releasees for any loss, damage, injury or death described above and I will indemnify and hold harmless Releasees and each of them from any loss, liability,damage or cost they may incur due to said minor’s presence in, upon or near the San Diego Cougars/Team PREP/Steel Canyon gyms;
whether caused by the negligence of Releasees or otherwise.

4. I assume full responsibility for, and risk of, bodily injury, death or property damage due to the negligence of Releasees or otherwise.

5. I do hereby authorize the San Diego Cougars/Team PREP /Educated Hoops agent for the undersigned, to consent with respect to said minor, to any x-ray examination, anesthetic, medical, dental, or surgical diagnosis or
treatment, and hospital care which is deemed advisable by, and is to be rendered under general or special supervision of, any physician and surgeon licensed under the provisions of the California Medical Practice Act on the medical staff of any hospital, whether such diagnosis or treatment is rendered at the office of the physician or at the hospital. I understand
that San Diego Cougars/Team PREP /Educated Hoops is not responsible for costs incurred for medical care.

6. San Diego Cougars/Team PREP/Educated Hoops may use my child’s photos for promotional purposes.

I intend this document to be as broad and inclusive as is permitted by the laws of the State of California; if any portion hereof is held invalid, I agree the balance shall continue in full
legal force and effect.

___________________________________________________________
Signature of Parent/Guardian Date

I/we agree with the above *

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San Dieo Cougars PREP Wavier