2014 CENTRAL JERSEY VOLLEYBALL CLUB

PERMISSION SLIP

CENTRAL JERSEY VOLLEYBALL AND RAHWAY RECREATION (732) 669-3600

 2013 GIRLS SUMMER VOLLEYBALL LEAGUE AGES; 13 AND OVER (entering grades 9-12 on 9/14) 

DATE: __/__/___  GRADE AS OF 9/14____________T-SHIRT SIZE________(Adult Sizes)

NAME OF PARTICIPANT:____________________________AGE:___

DOB: __/__/_____SEX: M___F___HIGH SCHOOL________________

HOME ADDRESS: ________________________________________

HOME PHONE: _____________ MOTHER'S NAME__________________________

WORK PHONE: _____________________

FATHER'S NAME: __________________________

WORK PHONE: ______________________

CHILD MAY ONLY BE RELEASED TO THE CHILD'S CUSTODIAL PARENT(S) OR PERSON(S) AUTHORIZED BY THE CUSTODIAL PARENT(S), TO ASSUME RESPONSIBILITY FOR THE CHILD IN AN EMERGENCY IF THE CUSTODIAL PARENT(S) CANNOT BE REACHED. CHILD MAY ONLY BE RELEASED TO THE CHILD'S CUSTODIAL PARENT(S) OR PERSON(S) AUTHORIZED BY THE CUSTODIAL PARENT(S), TO ASSUME RESPONSIBILITY FOR THE CHILD IN AN EMERGENCY IF THE CUSTODIAL PARENT(S) CANNOT BE REACHED. NAME_______________________ADDRESS__________________________PHONE________ NAME_______________________ADDRESS__________________________PHONE________ TO BE FILLED OUT BY A PARENT OR GUARDIAN: HEALTH HISTORY DOCTOR'S NAME & Dr NAME________________________________PHONE______________________ ALLERGIES__________________DISEASES____________________ASTHMA_____________OPERATIONS OR SERIOUS INJURIES(DATES)___________________________________ CHRONIC OR RECURRING ILLNESS__________________________________________ RECOMMENDATIONS AND RESTRICTIONS WHILE IN THE PROGRAM.__________ SPECIAL DIET:_______________CLASSIFICATION: ________________________ SPECIAL MEDICINE:________________IS PARENT SENDING IT?________________ IN THE EVENT I CANNOT BE REACHED IN AN EMERGENCY, I HEREBY GIVE PERMISSION TO THE PHYSICIAN SELECTED BY THE PARKS & RECREATION DIVISION, TO ADMINISTER EMERGENCY MEDICAL CARE FOR MY CHILD. 

 SIGNATURE OF PARENT OR GUARDIAN:_____________________________ 

 PARTICIPATION WAIVER AND RELEASE I HEREBY AGREE TO PARTICIPATE IN THE ABOVE PROGRAM(S) HOSTED AT THE RAHWAY RECREATION CENTER, RAHWAY HIGH SCHOOL, ROSELLE CATHOLIC HIGH SCHOOL AND MOTHER SETON REGIONAL HIGH SCHOOL DIVISION, BY IT’S EMPLOYEES, INSTRUCTORS, AND AGENTS UPON THE UNDERSTANDING AND CONDITION THAT: 1.)  I RECOGNIZE THE RISKS OF ILLNESS AND INJURY INHERENT IN ANY OF THE PROGRAMS MY CHILD WILL BE PARTICIPATING IN WITH THE DIVISION OF RECREATION UPON THE EXPRESS AGREEMENT AND UNDERSTANDING THAT I AM HEREBY WAIVING AND RELEASING CENTRAL JERSEY VOLLEYBALL CLUB LLC, THE RECREATION DEPT.,THEIR STAFF,THE CITY OF RAHWAY, AND THE PARTICIPATING HOST SCHOOLS FROM ANY AND ALL CLAIMS ARISING OUT OF MY CHILDS PARTICIPATION IN THE  PROGRAMS OR ANY ILLNESS OR INJURY RESULTING THEREFROM. I HEREBY FURTHER AGREE TO INDEMNITY AND HOLD HARMLESS CENTRAL JERSEY VOLLEYBALL CLUB LLC, THE RECREATION DEPT.,THEIR STAFF AND THE CITY OF RAHWAY FROM AND AGAINST ANY AND ALL SUCH CLAIMS. 2.)  I AGREE TO INFORM THE RECREATION DIVISION, AND CENTRAL JERSEY VOLLEYBALL OF ANY CHANGE IN MY PHYSICAL CONDITION WHICH MIGHT IN ANY WAY ADVERSELY AFFECT MY ABILITY TO PARTICIPATE IN ANY OF THE PROGRAM(S) SAFETY.

MY CHILD IS UNDER THE CUSTODIAL CARE OF: (CHECK ONE)

BOTH PARENTS____MOTHER ONLY________FATHER ONLY________

OTHER(PLEASE EXPLAIN)___________________

SIGNATURE OF PARENT OR GUARDIAN:______________________________