Tryout Participant Waiver Personal Information ...

UTRGV Walk-On/Tryout Participant Waiver Personal Information: Name: __________________________ Age: ________ Classification: ________________ Address: _________________________________ Cell Phone: _____________________ City: _____________ State:_____ Zip Code:_________ Email:_________________________ ID Number: ___________________ Emergency Contact: Name: __________________________________Phone Number: ________________________ Release and Liability Waiver: In recognition of, and with knowledge of, the fact that engaging in the sport of__________________ involves a substantial risk of personal injury, I, the undersigned, warrant that I am in good physical condition and hereby agree to assume the risk of any injury I may suffer as a result of my practice in _______________________ tryouts at The University of Texas Rio Grande Valley to be held on ___/___/_____. Therefore, in consideration for being permitted to participate in such tryouts, I hereby release, waive, and forever discharge The University of Texas Rio Grande Valley, the Athletic Department, and the UTRGV Medical Staff from any and every claim, demand or actions of whatever kind, arising from any bodily harm, personal injury or death resulting from accident which may occur as a result of participation in tryouts. Further, and to the same extent and scope, I release said parties from any claim whatsoever which may be attributable to the receipt of first aid or other emergency treatment rendered me in connection with my participation in such tryouts. I, understand, affirmatively swear that I am, at the time of signing, of legal age and fully competent to and do hereby execute this Release and Waiver on behalf of myself, my heirs, or assigns. I further represent and warrant that I have read and fully understand the terms of this document and their legal significance. In witness whereof I have voluntarily and without inducement from any party, executed this Release and Waiver on ___/___/_____. Name (Printed): ________________________________________ Date: ________________________ Signature: _____________________________________________ Date: ________________________ Witness Signature: ______________________________________ Date: ________________________ Compliance Signature: ___________________________________ Date: ________________________ Must be enrolled full-time at University of Texas Rio Grande Valley - (12 Hrs) Sports Med. Signature: ___________________________________ Date: ________________________ Must provide current physical examination – Must use UTRGV Athletics physical form AC 9/2012

AC 9/2012