Team Virginia Mizuno 2024/2025 Activity Waiver Registration

Team Virginia Mizuno Activity Waiver Registration

Complete the form below to participate in Team Virginia Athletics Sponsored Activities
Players Name*

First NameMiddle NameLast Name
Players E-Mail
example@example.com
Players Date of Birth*

MonthDayYear
List School Attending This Fall
Grade Entering This Fall*
Players Graduation Year*
Check Mizuno Team Participating With-*

8U Maine (Fauquier)10U Garrison (Charlottesville)10U Pappalardo (Fauquier)10U Thomas (Fauquier/Prince William)12U Patten (Prince William)12U Pearson (Loudoun)14U Arroyo (Prince William)14U Barkley (Loudoun)14U Ehrmantraut (Prince William)14U Hughes (Prince William)14U Reel (Front Royal)14U Wickline (Charlottesville)16U Cruz (Prince William)16U Culbertson/Medellin (Prince William)18U Lovell (Fauquier)18U Gary (Prince William)18U Russian/Mayhew (Prince William/Winchester)17U Baseball StephensTeam Virginia Athletics Activity
Activity-*

Open PracticeGuest PlayerCampOther
Positions Played*

PitcherCatcher1st2nd3rdSSOutfield
Primary Position *

PitcherCatcher1st2nd3rdSSOutfield
Bats-*
Throws-*
Additional Comments (include previous travel teams, playing experience)-
Guardian Name*

First NameLast Name
Guardian E-mail*
Guardian Phone Number*

Area CodePhone Number
Guardian#2 Name

First NameLast Name
Guardian#2 E-mail
Guardian#2 Phone Number

Area CodePhone Number
Players Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number*

Area CodePhone Number
In consideration of my participation in the foregoing, the undersigned acknowledge and agree to the following:*

I am aware of the existence of the risk on my physical appearance to the venue and my participation to the activity of the Organization that may cause injury or illness such as, but not limited to Influenza, MRSA, or COVID-19 that may lead to paralysis or death.I have not experienced symptoms that of fever, fatigue, difficulty in breathing, or dry cough or exhibiting any other symptoms relating to COVID-19 or any communicable disease within the last 14 days.I have not, nor any member(s) of my household, traveled by sea or by air, internationally within the past 30 days.I did not, nor any member of my household, visit any any area within the United States that was reported to be highly affected by COVID-19, in the last 30 days.I have not been, nor any member(s) of my household, diagnosed to be infected of COVID-19 virus within the last 30 days.
Following the pronouncements above I hereby declare the following:*

I am fully and personally responsible for my own safety and actions while and during may participation and I recognize that I may be in any case be at risk of contracting COVID-19.With full knowledge of the risks involved, I hereby release, waive, discharge the Organization, its board, officers, independent contractors, affiliates, employees, representatives, successors, and assigns from any and all liabilities, claims, demands, actions, and causes of action whatsoever, directly or indirectly arising out of or related to any loss, damage, injury, or death, that may be sustained by me related to COVID-19 while participating in any activity while in, on, or around the premises or while using the facilities that may lead to unintentional exposure or harm due to COVID-19.I agree to indemnify, defend, and hold harmless the Organization from and against any and all costs, expenses, damages, lawsuits, and/or liabilities or claims arising whether directly or indirectly from or related to any and all claims made by or against any of the released party due to injury, loss, or death from or related to COVID-19.
Informed Consent/General Release-All Participants

PLEASE READ CAREFULLY AND SIGN BELOW TO INDICATE YOUR AGREEMENT.
NOTE: THIS FORM INCLUDES A RELEASE OF LIABILITY.

Since participation in youth sports activities can be dangerous, Team Virginia Athletics requires that all participants (and their adult parent(s) or guardians) to assume all risks associated with all activities by signing this general release.

For and in consideration of my child being permitted to participate in Team Virginia Athletics / Team Virginia Mizuno activities, I hereby voluntarily release, discharge, waive and relinquish any and all claims or actions for damages for personal injury, permanent disability, death, pandemic illness, or property damage which I or my child may have, or which may here after accrue to me or my child, as a result of my participation in all activities during play and while I am at any facility while others play or for any other reason. This release is intended to discharge, in advance, Team Virginia Athletics / Team Virginia Mizuno, it’s officers, employees and agents, and the owners and maintainers of any facility used for practice or activities, from any and all liability arising out of or connected in any way with my child’s participation in camps/clinic activities, even though that liability may arise out of negligence or carelessness on the part of Team Virginia Athletics / Team Virginia Mizuno, its officers, agents or employees, or the owners or maintainers of any facility used by Team Virginia Athletics / Team Virginia Mizuno for practice or activities.

I further understand that serious accidents occasionally occur during youth activities, and that participants occasionally sustain serious personal injuries, death, pandemic illness or property damage as a consequence thereof. Knowing the risks, I have voluntarily applied for my child to participate in the activity and thereby agree to assume those risks to release and hold harmless Team Virginia Athletics / Team Virginia Mizuno, its officers, employees or agents, or the owners or maintainers of any facility used by Team Virginia Athletics / Team Virginia Mizuno for practice or activities, who (through negligence or carelessness) might otherwise be liable to me or to my child (or my heirs or assigns) for damages.

I further understand and agree that this release, discharge, waiver, and assumption of risk is to be binding on my and my child’s heirs, executors, administrators, and assigns.

I further agree to indemnify and to hold harmless Team Virginia Athletics / Team Virginia Mizuno, its officers, employees and agents, or the owners or maintainers of any facility used by the Team Virginia Athletics / Team Virginia Mizuno for practices or activities, for any loss, liability damage, cost or expense which may incur as a result of any injury or property damage I or my child may sustain while participating in the activity.

I agree to comply with the program’s stated and customary terms and conditions for participation according to the Team Virginia Athletics / Team Virginia Mizuno If I observe any significant change with regards to my child’s readiness for participation in the program, I will remove my child from the program immediately.

I have read this Informed Consent/General Release, fully understanding its terms, that I give up substantial rights by signing it, and sign it voluntarily.
DO NOT E-SIGN UNTIL YOU HAVE READ THE ABOVE STATEMENT.

By my eSignature below, I certify that I have read, fully understand and accept all terms of the foregoing statement. Please signify your acceptance by entering your full name in the box below
Are there any medical conditions the staff needs to be aware of?
Waiver of Liability Signature*

I accept the terms listed in the agreement above
Date*

MonthDayYear
Date
Parent's eSignature*
Signature*

Clear
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Team Virginia Mizuno Activity Waiver Registration