Participants Name : __________________ _____________________________ Circle: M F
(First) (Last)
School: _________________________________ Grade Next Fall: _________ DOB _____/_____/______
School Experience - Yrs: _____ Team(Var,JV,etc.): ____________ Club Experience - Yrs: _____ Position: __________
Participant's Address: _______________________________ City, State, & Zip Code: ________________________________
Participant's Phone Number: (______) ______-________ Cell: (______)______-________ E-Mail: _______________________________
Parent / Guardian: ___________________________________________
Parent's Address(If different): _________________________ City, State, & Zip Code: ________________________________
Parent's Phone Number- Home:(______)______-________ Mom Cell:(______)______-________E-Mail: _________________________
Dad Cell:(______)______-________ Other:(______)______-________E-Mail: _________________________
RELEASE AND HOLD HARMLESS AGREEMENT / AUTHORIZATION FOR TREATMENT OF A MINOR: In consideration of participation in 2011-2012 Del Rey
Volleyball & Beach Cities Volleyball Club activities (“activities”), including but not limited to tryouts, clinics, workouts, practices, beach tournaments, other tournaments,
competition, field trips and other activities, and with complete understanding said participant shall or may take a physical test of volleyball skills, I (we) understand and
agree to the following:
______________________________________________, participant is hereby given my consent to participate in tryouts, clinics, workouts, practices, beach
tournaments, other tournaments, competition, field trips and other activities with Del Rey Volleyball and Beach Cities Volleyball Club in 2011 and 2012. I give permission
for Del Rey Volleyball and Beach Cities Volleyball to use pictures of my child in the future for publicity use only.
Parent / Guardian Signature:________________________________________ Date:__________________
The undersigned does hereby waive, release, acquit and forever discharge all coaches and others associated with Del Rey Volleyball and Beach Cities Volleyball Club
and each of them from any and all acts, causes of action, claims, demands, damages, costs loss of service, expenses and compensation, on account of or which may in
any way develop out of any and all known and unknown personal injuries or property damages which the player/participant may suffer during the course of or as a result of
the participation in Del Rey Volleyball and Beach Cities Volleyball Club activities, including but not limited to the activities themselves, time spent after the activities,
and travel to and from the activities.
The undersigned does hereby waive, release, acquit and forever discharge Del Rey Volleyball and Beach Cities Volleyball Club, its officers and directors, collectively and
individually, coaches, and adult supervision, and any and all persons directly or indirectly associated with Del Rey Volleyball and Beach Cites Volleyball Club, and each
of them from any and all acts, causes of action, claims, demands, damages, costs or expenses on account of or which may in any way develop out of any and all known
and unknown personal injuries or property damages which the player/participant may suffer during the course of or as a result of participation with Del Rey Volleyball and
Beach Cities Volleyball Club throughout 2011 and 2012, including but not limited to tryouts, clinics workouts, practices, beach tournaments, other tournaments,
competition, field trips and other activities, and travel to and from the activities.
I hereby acknowledge that I am the lawful parent and/or guardian of the above-mentioned minor. I give authorization to any properly licensed physician or surgeon to
provide medical care and/or emergency treatment when necessary. Any expenditure for care and treatment is my responsibility.
Parent / Guardian Signature:__________________________________________ Date:___________________
Participant Signature:____________________________________ Date:___________________
Please Print Name of Parent / Guardian:____________________________________
Please Print Name of Participant:_____________________________________
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For Office Use only: Player’s Name ___________________________________ Phone #: ___________________________
E-Mail Address (es)___________________________________________________________________________
Del Rey Volleyball Tryout/Workout/Clinic
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Waiver & Application
(Please print)
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