Player Registration Form – Community Lifestyle

Player Registration

Participant's Information:

Last Name

Age

D.O.B

Gender:

School Name:

Height:

Weight:

Shirt size

Skill level

Age Division (CO-ED)

Age Division Girls Only

Parent's Information:

Second Parent's Information:

Home Address:

City:

State:

Zip:

Phone Number:

Alternate Number:

Who is Guardian?

Emergency Contact/Authorized Pick-Up:

Relationship to child

Phone Number

Emergency Medical Information

Asthma Diabetes Fainting Spells Convulsion

Emergency Medical Information

Contact Lens Heart Trouble High Blood Pressure Other

Other

Waiver Agreement

I hereby certify that I am the parent or legal guardian of and I am authorized to execute this Registration and Waiver on Participant’s behalf. I hereby certify that Participant is in normal health and can participate safely in the Community Lifestyle Programs/Events. I hereby authorize the Community Lifestyle Directors to act in my behalf in accordance with their best judgment in case of an emergency and to obtain necessary medical treatment for my child with the understanding that the family will be notified as soon as possible. I, on my own behalf and on behalf of Participant, hereby forever release and discharge the Community Lifestyle and the subsidiaries, affiliates, parent companies, partners, predecessors, assigns, present and former officers, owners, shareholders, directors, agents, and employees of each and every one of the aforesaid entities against any and all causes of action, claims, suits, controversies, agreements, promises, judgments, demands or claims whatsoever, that I or my spouse, heirs, executors, administrators, successors or assigns have or hereafter, at any time, shall or may have arising out of or in connection with Participant’s participation in the Community Lifestyle Programs/Events, whether arising due to negligence or otherwise. In consideration of the good will, public service, and community aid provided by Community Lifestyle, which I support and from which I have received benefit, I hereby grant permission to Community Lifestyle to use Participant’s name, to take and publish photographs, videotapes or motion pictures of him/her which include his/her voice, in any media for any legitimate purpose. I release all rights to such photographs, videotapes, motion pictures and recordings. I acknowledge that you are the sole owner of all rights arising out of their use for all purposes. I understand that I shall receive no compensation from their use from any source whatsoever. I, as a parent or guardian, am willing to participate as a volunteer in support of this program to the extent that I am able (subject to reference and background check)