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

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PLAYER INFORMATION

* First Name:

* Last Name:

Street:

City:

State:

Zip Code:

Home Phone:

Birthdate:

Email:

Gender:

Grade:

* AAU Number:

* Uniform Size:

School:

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 #:

WAVIER INFORMATION

RELEASE/WAIVER FOR Athletic Iniative/Educated Hoops/Jackie Robinson YMCA (MINORS)
Name of Minor ___________________________________________________

Please Print

I, the undersigned parent/person having legal custody/guardianship of the above said minor, give permission for the minor to participate in all Athletic Initative/Educated Hoops 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 Jackie Robinson YMCA 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. Jackie Robinson Family YMCA, 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 Athletiv Initative Hoops 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 Jackie Robinson YMCA Center; 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 Educated Hoops/Athletic Initative 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 Educated Hoops/Jackie Robinson YMCA is not responsible for costs incurred for medical care.

6.Educated Hoops/Jackie Robinson YMCA/ Athletic Initative 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 *

Signature:

Date:

Signature:

Date:

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Increase the Peace Stop the Violence