Registration

EMERGENCY INFORMATION

AND WAIVER

This information is required for each player and will apply to all clinics / sessions.

Please direct inquiries to Lena Chan at lena@athenavb.net.

PLAYER INFORMATION

Player Name *

First Last

Birthdate *

Month Day Year

Gender *

Female Male

PARENT / GUARDIAN INFORMATION

Parent / Guardian Name *

First Last

Mobile Number *

Home Number

Email *

example@example.com

SECONDARY EMERGENCY CONTACT INFORMATION

Name *

First Last

Relationship *

Mobile Number *

Alternate Number *

INSURANCE AND PHYSICIAN INFORMATION

Medical Insurance Company *

Group Number *

Policy Number *

Policy Holder *

Medical Insurance Phone Number *

Hospital of Choice *

Physician's Name *

First Last

Physician's Phone Number *

MEDICAL HISTORY

Does the player have any allergies that we need to be aware of? *

Yes No

If yes, please list:

Does the player have any medical conditions that we need to be aware of? *

Yes No

If yes, please list:

CONCUSSION INFORMED CONSENT FORM

Agreement: *

I/We have read, understood, and agree to comply with the INFORMED CONSENT FORM as outlined above.

Participant Signature (regardless of age):

Parent / Legal Guardian Signature:

Date

Month Day Year

ASSUMPTION OF RISK AND WAIVER OF LIABILITY

RELATING TO CORONAVIRUS / COVID-19

Agreement: *

I/We have read, understood, and agree to comply with the ASSUMPTION OF RISK AND WAIVER OF LIABILITY RELATING TO CORONAVIRUS / COVID-19 as outlined above.

Participant Signature (regardless of age):

Parent / Legal Guardian Signature:

Date

Month Day Year

WAIVER

RELEASE OF ALL CLAIMS AND CONSENT TO MEDICAL TREATMENT

In consideration of the acceptance of my entry and application to attend the Volleyball Clinic, I hereby release and hold harmless the officers, directors, staff and members of the Volleyball Clinic, from any liability, illness or property damage, that I sustain during my participation in this camp or that is in any way related to this camp. I understand that this Release applies to myself, my child (if signed by a parent or guardian), and our respective personal representatives, heirs and assigns. I represent that I or my child or ward is adequately trained to participate in this event, that I recognize the risks of injuries accompany such participation and that I acknowledge that this Release is being relied upon by all the above persons in permitting me to participate. Each player will be solely covered by the personal insurance of the individual signing the waiver.

If, as a result of my participation in the Volleyball Clinic, I require medical attention, I hereby give my consent to the above personnel to seek medical care for myself or my child or ward, (in the case of a parent or guardian) as is deemed necessary by authorized personnel of the camp or medical care providers. I hereby grant permission to the clinicians, its successors and assigns to use any photographs, video tapes, motion pictures,

recordings or other record of the camp and my participation or that child or ward, for any legitimate reason.

Electronic Signature: *

I/We have read, understand and agree to comply with the RELEASE OF ALL CLAIMS AND CONSENT TO MEDICAL TREATMENT as outlined above.

Parent / Legal Guardian Signature:

Date

Month Day Year

.