2014 Central Jersey Volleyball Club Junior League
PARENT/GUARDIAN CONSENT AND AGREEMENT
I
acknowledge that as a member of the Central Jersey Volleyball Club Junior League, my daughter will participate in activities
that involve physical activity, including physical contact with other persons and for objects such as the ground, sport equipment,
facilities, etc. that may incur injury. I specifically waive and release the Central Jersey Volleyball Club, administrators
and volunteers of the Central Jersey Volleyball Club from liability from any claim(s) for damages for injuries/illnesses which
my daughter may sustain during her involvement in the athletic program.
In
signing this form, I certify that my child is in good health, with no chronic illness or injury. If such conditions exist,
I will notify the Central Jersey Volleyball Club of such conditions prior to my child's participation. In the event of any
emergency in which my daughter requires medical treatment, I authorize the staff of the Central Jersey Volleyball Club Junior
League to act on my behalf to obtain proper medical treatment, the staff member, in their best judgment, deems necessary and
appropriate for my daughter. This will include, but not be limited to whatever necessary medical, surgical and dental examination,
diagnosis and/or treatment that is deemed necessary by the treating physician.
In signing
this form, my family, and I agree to follow all rules and regulations of the Central Jersey Volleyball Club Junior League.
Athlete's
Name: (print)__________________________________________________
Home Street
Address: ___________________________________________________
City:__________________State:_____Zip___________________________________
School
: ___________________________________Grade: (as of 9/14)_____________
Parent/Guardian
Name: (print)____________________________________________
Emergency
Phone Numbers: HOME (
) ______________________________
WORK:( ) ______________________________
Email
Address _______________________________________________________
Parent/Guardian
Signature: _____________________________________________
Today's
Date ________________________________________________________
PERMISSION/RELEASE
FORM
Player's
Name ________________________Date of Birth___________ Age___
Address _____________________________City_______________State_____
School
________________________________________________ Grade_____
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EMERGENCY
CONTACT PERSON(S):
Name______________________________
Phone _______________________
Address ___________________________ City _________________________
Name______________________________
Phone _______________________
Address
___________________________ City _________________________
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I give
permission for my child to practice and play for the Central Jersey Volleyball Club Junior League during the 2014-15 season. I hereby waive and release any and
all rights and claims for damages which I may have against any coach or agent of the Central
Jersey Volleyball Club Junior League for any and all injuries which my child may incur while taking part in your program.
This release also encompasses any injuries which may be sustained while traveling to and from participation in your program.
As a parent, I understand it is my responsibility to pick my child at the predetermined time and location- I also understand
that if my child becomes ill or destructive, the above EMERGENCY CONTACT PERSON(S): will be called to take my child home if
I cannot be contacted immediately.
Parent/Guardian Signature:____________________
Parent/Guardian Signature:______________________
Date;__________________ Telephone ( ) ______________________________
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HEALTH
HISTORY:
Does your son/daughter have any medical problems or allergies that we should be informed about? YES____NO
____
lf yes, please explain? _____________________________________________________
Is your son/daughter on any medications? YES____NO ____
If yes, please describe the type of medication, dosage, frequency of use and who is authorized in the administration
_______________________________________________________________________
PARENTS AUTHORIZATION: This Health History is correct
so far as I know. I understand that this information will be kept strictly confidential and will be used in cases of injury
or sickness and will be presented to medical personnel who might have to attend to my child in an emergency.
PARENTS
SIGNATURE: __________________________________________DATE:___________
