Athlete Waiver Form V1

Athlete Waiver Form

Please complete our Athlete Waiver Form below if you have any concerns please contact jean@usatouch.org
Your Team Name
Athlete Information
Name

First NameLast Name
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Contact Number

Area CodePhone Number
Birthdate

MonthDayYear
Date
I am interested in

Referee CertificationUSA World Cup Team
Referee Level
Which Division?
Age on Jan 1 2019
Emergency Information
Emergency Contact Name

First NameLast Name
Relationship
Area CodePhone Number
Do you have any allergies?

YesNo
Please Describe
Do you have any medications?

YesNo
Please Describe
Inform Consent and Acknowledgement

I hereby give my approval for participation in any and all activities of the USA Touch Rugby Association. I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless the USA Touch Rugby Association, and all its respective officers, agents, and representatives from any and all liability for injuries to said athlete arising out of travel to, participating in, or returning from practices and tournaments conducted during touch seasons.

There is a risk of being injured that is inherent in all sports activities. Some of these injuries include, but are not limited to, the risk of fractures, paralysis, head trauma or death.

In case of injury, I hereby waive all claims against the USA Touch Rugby Association, including all coaches and affiliates, all participants, sponsoring agencies, advertisers and if applicable, owners and lessors of premises used to conduct the event.

Furthermore all images and videos of the USA Touch Rugby Association are the property of USA Touch Rugby Association and can be used for any promotional consideration.

I agree to the policies and laws of USA Touch Rugby Association with reference to eligibility, rules and regulations, conduct on and off the field and recognize that I am responsible for consequences should I breach any of the rules, regulations, eligibility guidelines and other USA Touch Rugby Laws.

I hereby state that I have carefully read the above waiver. Acceptance and understanding of this agreement are hereby acknowledged.
I the athlete have read and agree to the Inform Consent and Acknowledgement.
Please Initial *
I the guardian have read and agree to the Inform Consent and Acknowledgement.
Please Initial *
Medical Release and Authorization

I hereby authorize the diagnosis and treatment by a qualified and licensed medical profession, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the athletes life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named athlete. In the event of an emergency arising out of serious illness the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me.

Permission is also granted to the USA Touch Rugby Association Director/Coach/Team Manager to provide the needed emergency prior to the athlete admission to the medical facility.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named athlete.
I the athlete have read and agree to the Medical Release and Authorization
Please Initial *
I the guardian have read and agree to the Medical Release and Authorization
Please Initial *
Confirmation

By entering the information below, I am delivering an electronic signature that will have the same effect as an original manual paper signature. The electronic signature will be equally as binding as an original manual paper signature.
Athlete Signature
Athlete Full Name

First NameLast Name
Confirmation

By entering the information below, I am delivering an electronic signature that will have the same effect as an original manual paper signature. The electronic signature will be equally as binding as an original manual paper signature.
Parent/Guardian Signature
Parent/Guardian Full Name

First NameLast Name
Should be Empty:

Athlete Waiver Form

Athlete Information

Emergency Information