Houston Slam Volleyball Form and Waiver 1333 Gears Rd. Apt# 2405 Houston, Texas 77067 (832) 605-5968 Camp Registration Shirt Size: YL YXL S M L XL XXL Players Information: First Name: __________________________________________ MI: _____ Last Name:___________________________________________________ Address: ____________________________________________________ City: ________________________ Zip: _______________ Birthdate ________/__________/_________ Grade:__________ School: _________________________________ Club Team: ___________________ Phone: ( ) ____________________________ email: _______________________ Parents/Guardian Name _______________________________________________________ Address: _____________________________________________________ Phone: ( ) _______________________ email: ____________________________ Occupation: ___________________________________________________________ Signature (parent/guardian) ___________________________________ Date: _______ Page 1 of 3 Cancellation Policy: ** If you cancel after the deadline, but prior to the start date you will only be refunded 50%. No refunds will be given after the start of the league** Participatipation Waiver: In consideration of being allowed to participate in the program is significant, including the potential for permanent paralysis and death. I knowingly and freely assume all such risk, both known and unknown, even if arising from the negligence of the releasees or others. I willingly agree to comply terms and conditions for participation. I observe any unusual significant hazard during my presence or participation, I will remove myself from participation and bring such to the attention of the nearest official immediately. I, for myself and on behalf of my heirs, assign, personal representation and next of kin, hereby release, indeminify, and hold harmless Houston Slam Volleyball, its officers, officials, agents and/or employees, othe participants, sponsors, advertisers, and if applicable, owners and lessors or premises used by leasees), from any and all claims, demands, losses, and liability arising out of or related to any injury, disability or death I may suffer, or loss or damage to person or personal property, whether arising from the negligence of the releasees or otherwise, to the fullest extent permitted by law. I have read this release of liability and assumption of risk agreement, fully understand its terms, understand that I have given up substantial rights by signing it and sign it freely and voluntarily without and inducement. Print Participant's Name: _____________________________________________ X______________________________________________ ________ _______ Participant's Signature Age Date For parent's/gaurdians of participants or minor age (under age 18 at time of registration.) This is to certify that I, as parent/guardian with leg I responsibility for this participant, do consent and agree to his/her release as provided above of all the Releasees, and for myself, my heirs,assigns, and next of kin, I release and agree to indemnify and hold harmless the Releasees from any and all liability incidents to my minor child's involvement of particpantion in these programs as provided above, even if arising from the negligence of the releeses, to the fullest extent permitted by law. X__________________________________________ ________ ________ ________________________ Parent's Signature Age Date Emergency Phone Number Page 2 of 3 Club Registration Name:__________________________________________D.O.B.___/___/_____ Address:_________________________________City______________________ Zip_________ Home Phone__________________________________________ Grade 2010/2011________ School___________________________________ Email______________________________________ Cell____________________ PARENT or GUARDIAN INFORMATION Name___________________________________________ Phone___________________________________________ Email___________________________________________Cell_______________ Address_________________________________________ City______________________________Zip____________ Consent Statement I hereby give permission for my daughter/son to participate in the Slam Volleyball Club. This authorization shall waive, release, and absolve the Slam Volleyball Club and Staff from liability for injury or illness incurred at the camp. I give the camp staff permission to act for me according to its best judgment in case of emergency. Signed_________________________________________________ Date___________________________________________________ Name of Insured _________________________________________ Insurance Carrier_________________________________________ Policy Number___________________________________________ (Please attach copy of insurance card)Double-click here to edit the text. 3 of 3 |
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