youth all skills volleyball clinic
MOHS JUNIOR/YOUTH ALL SKILLS VOLLEYBALL CLINIC (Please print clearly)
PLAYER NAME:_________________________________________________ BIRTHDATE:____________________________________ ADDRESS:____________________________________________________________________________________________________ HOME PHONE:______________________________________EMAIL:____________________________________________________ CELL PHONE:______________________________________ALTERNATE CONTACT:_________________________________________ PARENT/GUARDIAN INFORMED CONSENT I hereby grant permission for ______________________________________(PLAYER NAME) to participate in the MOHS Junior/Youth All Skills Volleyball Clinic on 6/26/17 – 6/29/17. Further, I authorize the Program to provide emergency medical treatment of an injury or illness of my child if qualified medical personnel consider treatment necessary and perform the treatment. I understand that I am responsible for the cost associated with any medical treatment my child receives. This authorization is granted only if I cannot be reached and a reasonable effort has been made to do so. PARENT/GUARDIAN (PRINT):____________________________________________________________________________________ SIGNATURE:__________________________________________________________DATE:___________________________________ FAMILY PHYSICIAN:_______________________________________________TELEPHONE:___________________________________ PRE-EXISTING MEDICAL CONDITIONS (i.e. ASTHMA, ALLERGIES):________________________________________________________ MEDICATIONS TAKEN:_____________________________________EMERGENCY CONTACT:__________________________________ TELEPHONE:__________________________________________RELATIONSHIP TO PLAYER:__________________________________ WAIVER AND RELEASE OF LIABILITY My child and I acknowledge that volleyball or any sporting event is an extreme test of a person’s physical and mental limits and that my child’s participation in a volleyball event can cause potential death, serious injury, or property damage. With a full understanding of the potential risks, I hereby assume the risks on behalf of my child in participating in the MOHS Junior/Youth All Skills Volleyball Clinic. I hereby take the following action for myself, my child, my executors, administrators, heirs, next of kin, successors and assigns: a) I waive, release, and discharge from any and all claims or liabilities for death or personal injury or damages of any kind, except that which is the result of gross negligence and/or wanton misconduct of persons or entities associated with the MOHS Junior/Youth All Skills Volleyball Clinic, which arise out of or relate to my child traveling to and from or my child’s participation in any volleyball event; b) I agree not to sue any of the persons or entities associated with the MOHS Junior/Youth All Skills Volleyball Clinic for any of the claims or liabilities that I have waived, released or discharged herein; and c) I indemnify and hold harmless the persons or entities associated with the MOHS Junior/Youth All Skills Volleyball Clinic from any claims made or liabilities assessed against them as a result of my actions. I UNDERSTAND THIS INFORMED CONSENT FORM AND AGREE TO ITS CONDITIONS ON BEHALF OF MY CHILD. PARENT/GUARDIAN SIGNATURE:___________________________________________DATE:_________________________________ Please make check payable to : MOHS VB Parents Club Mail to: Kelly Ward, 12 Rehoboth Road, Flanders, NJ 07836 Please select the session your child will participate in (circle one): AM Session (9am - 12pm) Ages 5-8 My Buddy and Me $125
AM Session (9am - 12pm) th th Incoming 4 – 9 graders $125
PM Session (1pm - 4pm) th th Incoming 4 – 8 graders $125
PM Session (1pm - 4pm) th Incoming 9 graders (freshmen) $125
PLAYER NAME:_________________________________________________ BIRTHDATE:____________________________________ ADDRESS:____________________________________________________________________________________________________ HOME PHONE:______________________________________EMAIL:____________________________________________________ CELL PHONE:______________________________________ALTERNATE CONTACT:_________________________________________ PARENT/GUARDIAN INFORMED CONSENT I hereby grant permission for ______________________________________(PLAYER NAME) to participate in the MOHS Junior/Youth All Skills Volleyball Clinic on 6/26/17 – 6/29/17. Further, I authorize the Program to provide emergency medical treatment of an injury or illness of my child if qualified medical personnel consider treatment necessary and perform the treatment. I understand that I am responsible for the cost associated with any medical treatment my child receives. This authorization is granted only if I cannot be reached and a reasonable effort has been made to do so. PARENT/GUARDIAN (PRINT):____________________________________________________________________________________ SIGNATURE:__________________________________________________________DATE:___________________________________ FAMILY PHYSICIAN:_______________________________________________TELEPHONE:___________________________________ PRE-EXISTING MEDICAL CONDITIONS (i.e. ASTHMA, ALLERGIES):________________________________________________________ MEDICATIONS TAKEN:_____________________________________EMERGENCY CONTACT:__________________________________ TELEPHONE:__________________________________________RELATIONSHIP TO PLAYER:__________________________________ WAIVER AND RELEASE OF LIABILITY My child and I acknowledge that volleyball or any sporting event is an extreme test of a person’s physical and mental limits and that my child’s participation in a volleyball event can cause potential death, serious injury, or property damage. With a full understanding of the potential risks, I hereby assume the risks on behalf of my child in participating in the MOHS Junior/Youth All Skills Volleyball Clinic. I hereby take the following action for myself, my child, my executors, administrators, heirs, next of kin, successors and assigns: a) I waive, release, and discharge from any and all claims or liabilities for death or personal injury or damages of any kind, except that which is the result of gross negligence and/or wanton misconduct of persons or entities associated with the MOHS Junior/Youth All Skills Volleyball Clinic, which arise out of or relate to my child traveling to and from or my child’s participation in any volleyball event; b) I agree not to sue any of the persons or entities associated with the MOHS Junior/Youth All Skills Volleyball Clinic for any of the claims or liabilities that I have waived, released or discharged herein; and c) I indemnify and hold harmless the persons or entities associated with the MOHS Junior/Youth All Skills Volleyball Clinic from any claims made or liabilities assessed against them as a result of my actions. I UNDERSTAND THIS INFORMED CONSENT FORM AND AGREE TO ITS CONDITIONS ON BEHALF OF MY CHILD. PARENT/GUARDIAN SIGNATURE:___________________________________________DATE:_________________________________ Please make check payable to : MOHS VB Parents Club Mail to: Kelly Ward, 12 Rehoboth Road, Flanders, NJ 07836 Please select the session your child will participate in (circle one): AM Session (9am - 12pm) Ages 5-8 My Buddy and Me $125
AM Session (9am - 12pm) th th Incoming 4 – 9 graders $125
PM Session (1pm - 4pm) th th Incoming 4 – 8 graders $125
PM Session (1pm - 4pm) th Incoming 9 graders (freshmen) $125
