Avenger's Junior Volleyball League

PARENT/GUARDIAN CONSENT AGREEMENT MEDICAL WAIVER

I acknowledge that as a member of the Avenger’s Junior Volleyball League, my daughter/son will participate in activities that involve physical activity, including physical contact with other persons and for objects such as the ground, sport equipment, facilities, etc. that may incur injury. I specifically waive and release the Avenger’s Junior Volleyball League, St. George's Church, administrators and volunteers of the Avenger’s Junior Volleyball League from liability from any claim(s) for damages for injuries/illnesses which my daughter/son may sustain during her/his involvement in the athletic program.

In signing this form, I certify that my child is in good health, with no chronic illness or injury. If such conditions exist, I will notify the Avenger’s Junior Volleyball League of such conditions prior to my child's participation. In the event of any emergency in which my daughter/son requires medical treatment, I authorize the staff of the Avenger’s Junior Volleyball League to act on my behalf to obtain proper medical treatment the staff member, in their best judgment, deems necessary and appropriate for my daughter/son. This will include, but not be limited to whatever necessary medical, surgical and dental examination, diagnosis and/or treatment that is deemed necessary by the treating physician.

In signing this form, my family, daughter/son and I agree to follow all rules and regulations of the Avenger’s Junior Volleyball League.

PLAYER INFORMATION

* First Name:

* Last Name:

Street:

City:

State:

Zip Code:

School Name:

* Parent\Guardian Name:

* Emergency Home Phone:

* Emergency Cell Phone:

* Email:

* PARENT/GUARDIAN Signature:

* Today's Date:

Permission Release Waiver

* Player's Name:

* Address:

* Date of Birth:

* Age:

* School Name:

* Emergengy Contact Information (1):

Name:

Address:

* Phone:

Emergengy Contact Information (2):

Name:

Address:

Phone:

I give permission for my child to practice and play for the Avenger’s Junior Volleyball League during the 2019-2020 season. I hereby waive and release any and all rights and claims for damages which I may have against any coach or agent of the Avenger’s Junior Volleyball League and St George's Church for any and all injuries which my child may incur while taking part in your program. This release also encompasses any injuries which may be sustained while traveling to and from participation in your program. As a parent, I understand it is my responsibility to pick my child at the predetermined time and location- I also understand that if my child becomes ill or destructive, the above EMERGENCY CONTACT PERSON(S): will be called to take my child home if I cannot be contacted immediately

* PARENT/GUARDIAN Signature:

* Date:

HEALTH HISTORY:

* Does your son/daughter have any medical problems or allergies that we should be informed about?:

Yes

lf yes, please explain?:

* Is your son/daughter on any medications?:

Yes

If yes, please describe the type of medication, dosage, frequency of use and who is authorized in the administration:

PARENTS AUTHORIZATION:
This Health History is correct so far as I know. I understand that this information will be kept strictly confidential and will be used in cases of injury or sickness and will be presented to medical personnel who might have to attend to my child in an emergency.

* Parent\Guardian Signature:

Date:

I/we agree with the above *

* indicates required fields

OUR SERVICES

LOCAL SPORTS

ELITE

PARENT/GUARDIAN CONSENT AGREEMENT MEDICAL WAIVER