AND
WAIVER/LIABILITY RELEASE FORM
I / We understand that the “participant”
(child) has made application to be enrolled in the activities sponsored with
• I/ We, the participant and legal guardian understand that
there are risks of personal injury associated with the participation in all
athletic programs, events, and activities, which can result in
temporary/permanent disabilities, death, severe personal loss and economic
damages.
• I/ We, the participant and legal guardian understand that
L.C.Y.C. will not provide accidental insurance and takes no responsibility for
monitoring and assessing the health and physical condition for the participant.
IN CONSIDERATION OF THE
ACCEPTANCE OF THE PARTICIPANT TO ENROLL IN THE LOWNDES COUNTY YOUTH COUNT:
SPORTS PROGRAM, AND WITH THE KNOWLEDGE OF THE ASSOCIATED RISK TO THE
PARTICIPANT, I / WE AGREE TO THE FOLLOWING:
• I /We consent to the participant
enrolling in the L.C.Y.C. and participating in the events and activities which
constitute the program.
• I / We will instruct the
participant to review and carefully follow all of the L.C.Y.C. guidelines,
rules and procedures of safety and general deportment, whether or not the
participant is engaged in training events or activities at the time.
• I / We accept and assume full
responsibility for consulting with a doctor about the L.C.Y.C. programs and
hereby warrant, represent, and state that the participant named below is in
good physical condition and that the participant has no disability, impairment,
or ailment that would prevent him/her from engaging in the L.C.Y.C. program or
any of the events or activities or that would be detrimental to his/her health,
safety, comfort or physical condition. In the case of emergency, I/We grant
permission for medical treatment to be given at a local hospital.
• I / We accept and assume all risk
and responsibility for accidents, illness, injury, and/or damages which may
result from the participant traveling to/from or participating in any of the
events or activities associated with the L.C.Y.C. program, and hereby waive,
release and discharge, Lowndes County Children’s Policy Council, Lowndes County
Youth Count, City/Town or area where event/activity/incident is held, Lowndes
County Public School System, employees, volunteers, agents and/or anyone
associated and therefore:
I / WE HAVE
READ THE FOREGOING AND UNDERSTAND THAT ITS TERMS INCLUDE MY/OUR CONSENT AND
MY/OUR
AGREEMENT TO TAKE CERTAIN ACTIONS, TO ASSUME CERTAIN RESPONSIBILITIES AND TO
RELEASE
LOWNDES
KNOWLEDGE OF
ITS SIGNIFICANCE. (A COPY OF THIS FORM IS AVAILABLE UPON REQUEST)
CHILD’S FULL
NAME (PRINT): ________________________
AGE: ________
BIRTH DATE:
________/__________/__________ SCHOOL:
GRADE:
CHILD’S HOME
ADDRESS: _____________________________ CITY: _____________________
ZIP:
______________ HOME PHONE: ________
ALT PHONE: _________
PARENT/GUARDIAN
NAME (PRINT): ___________________________________
PARENT/GUARDIAN
SIGNATURE: __________________________________ DATE:
______________
EMAIL:
WE ENCOURAGE
ALL PARENTS/GUARDIANS TO VOLUNTER. IF YOU ARE ABLE TO DO SO INFORM YOUR CHILD’S
COACH. ALSO, AS AN ADDITIONAL BENEFIT FOR YOUR CHILD, ENROLLMENT IN L.C.Y.C PLACES
YOUR CHILD IN A POSITIVE MENTORING PROGRAM THAT IS DESIGNED TO ADD TO THE
POSITIVE GROWTH AND DEVELOPMENT OF EACH CHILD.
THANK YOU FOR
YOUR SUPPORT
************************************************************************************************************************************************
Child is interested
in the following sport(s). ___
Baseball ___ Softball ___T-Ball ___Soccer
___Track ___Volleyball ___Flag Football ___Football ___Basketball ___Cheerleading ___Karate
Child is
already in a League? _____Yes ___No: If yes, what is NAME/LOCATION
___________________________
CHECK ONE: T-BALL ___ (AGES 3-6) MACHINE-PITCH ___ (AGES 7-8)
MINORS ___ (AGES 9-10) MAJORS ____ (AGES 11-12)
Contact:
Pauline Luvene at 334-233-8484 or Fax at 334-356-7681
The Lowndes
County Children’s Policy Council Project (2006).