Advance Program's Medical  History, Release & Waiver Form

Athlete's Reg. Info:     Name (Last)_________________________   First______________________   Gender (M/F)______

School _____________________  Grade ____  Age ____  Birth date ___/___/___  Height _____  Expected Graduated Year ________

Only positions excel in (by order: 1, 2, ...)  __Setter __Middle __Libero __Outside Hitter (Left) __Def Specialist __Opp Hitter (Right side)

Parents Name:_________________________  Address: ______________________________Home  #: (______)_______________

(If under 18 yrs old)

                                                  City/State:______________________________    Zip: __________  Cell  #: (______)_______________

Permission to Play   Participant, _______________________________, has my permission to participate in training, competition, events and activities associated with the "Advance Training" & "Advance Extra" & "Advance Volleyball" Program I approve of the leaders who will be in charge of this program. I recognize that the leaders are serving to the best of their ability. I certify that the participant has full medical insurance with the company listed on page 2. I also certify to the best of my knowledge that the participant named hereon is physically fit to engage in the activities described above.

Waiver:  I Acknowledge that volleyball or any sporting event is an extreme test of a person’s physical and mental limits and carries with it the potential for death, serious injury, or property loss. I HEREBY ASSUME THE RISKS OF PARTICIPATING IN THE ADVANCE VOLLEYBALL PROGRAM.  I hereby take the following action for myself, my executors, administrators, heirs, next of kin, successors and assigns: a) I WAIVE, RELEASE, AND DISCHARGE from any and all claims or liabilities for death or personal injury or damages of any kind, which arise out of or relate to my participation in, or my traveling to and from the volleyball event, THE FOLLOWING PERSONS OR ENTITIES: The Parks & Recreation Department, The City of Lorain and Elyria, The Advance Volleyball Program Directors, The Program Directors, Sponsors; and the officers, directors, employees, representatives, and agents of any of the above; b) I AGREE NOT TO SUE any of the persons or entitles mentioned above for any of the claims or liabilities that I have waived, released or discharged herein; and c) I INDEMNIFY AND HOLD HARMLESS the persons or entities mentioned above from any claims made or liabilities assessed against them as a result of my actions.

The undersigned,           (Guardian) _________________________________________ the parent and natural guardian of legal

guardian of (Minor's Name/Athlete) __________________________________________ hereby executed the foregoing Waiver and Release for and on behalf of the minor named herein. I hereby bind myself, the minor and all other assigns to the terms of the Waiver and Release. I represent that I have legal capacity and authority to act for and on behalf of the minor named herein, and I agree to indemnify and hold harmless the persons or entities mentioned above for any claims or liabilities assessed against them as a result of any insufficiency of my legal capacity or authority to act for and on behalf of the minor in the execution of the Waiver and Release

Emergency Release Form Section    If, during the course of my child's (athlete/participant) activities in volleyball and training, if they should become ill or sustain an injury, I hereby authorize the club directors, instructors and coaches affiliated with Advance Volleyball Program to obtain emergency medical/dental care.

______  I WILL ASSUME  financial responsibility for the bills incurred through my Insurance Company AND/OR my 

                 parents or Guardian's Insurance company.

_______  I DO NOT authorize emergency medical/dental care for my daughter / son.

            instructions in case of Emergency:    __________________________________________________________________

                                Parent or Guardian (if under 18) Signature___________________________ Date (mm/dd/yy) _____________

Athlete's / Participant's Medical and Health History     

Is participant allergic to any medications if injury should occur and has to be treated? NO _____ YES ____  If YES name

Allergic Medication (s) ________________________________________________________________________________

Any Joint injuries (Ankle, Knee, Back, Neck, Wrist, Elbow, etc.) NO _____ YES _____ If Yes, Please state the type, location, and date of injury and conditions: 

Does athlete have or had used an inhaler in the past 2 years: NO___ YES___  

If Yes, participant must bring Inhaler or they may not participate in that days Activities..   (Mandatory)

Any Injuries in the past 2 months or medical conditions we should be aware of (please detail on back)     Advance v.5.0.1208