Juventus Premier Futbol Club 2007-2008

Piccolini Registration

Release and Waiver of Liability, Assumption of Risk, Indemnity Agreement, and Authorization to Treat

Participant’s First Name: __________________ Last Name: ___________________

Street Address: ________________________________Apt#___________________

City: ______________________ State: _______________ Zip Code: ____________

Phone #: _____________________ Date of Birth: ___________________________

E-mail Address: ______________________________________________________

Parents’/Guardians’ Name(s): ___________________________________________

Emergency Contact Number: ___________________________________________

Shirt Size: ___________    Short Size: ___________   Sock Size: ___________

Juventus Premier Futbol Club does not carry or participate in any insurance contract whether for group or individually. No medical insurance of any type is provided. In consideration of Juventus Premier Futbol Club permitting my son/daughter to participate in its activities and events, permitting my son/daughter to use training equipment as needed, I hereby agree as follows:

1. Parent/Guardian states and agrees that the minor child is adequately covered by insurance elsewhere and imposes no fault on Juventus Premier Futbol Club, First Baptist Church Maryville, or any of its staff, coaches, or associated individuals.
2. To waive any and all claims that I have or may in the future have against Juventus Premier Futbol Club, its directors, employees, agents and representatives.
3. The minor child and the minor child’s family agree to indemnify and hold harmless Juventus Premier Futbol Club, First Baptist Church Maryville, the leagues and associations with which they belong or subscribe, the staff, coaches, and associated individuals, parents or any other individuals including those who transport them to/from tryouts, practices, and games for any damages or injuries to the child as a result of his/her participation in the Juventus Premier Soccer Club.
4. I further give my permission for the free use of the participant’s name and image in broadcast, telecast, or other media account of any and all events/activities and for the promotional purposes of Juventus Premier Futbol Club.
5. I hereby give my consent to have an athletic trainer, coach, team manager, emergency medical technician, nurse, medical treatment facility, and/or doctor of medicine or dentistry or associated personnel provide the participant with medical assistance and/or treatment and agree to be financially responsible for the cost of such assistance and/or treatment.
6. I understand that treatment for injury will be based on information provided herein.
7. I hereby authorize emergency transportation of the participant to a medical treatment facility should and individual listed in number five consider it to be warranted.

_________________________________ _____________________

Parent/Guardian Signature/Relation to Player Date