Player Name
*
First Name
Last Name
Player Birthdate
*
MM
DD
YYYY
Player gender
*
Female
Male
School during season
Player T-shirt size
*
YS
YM
YL
YXL
AS
AM
AL
Emergency Contact
*
First Name
Last Name
Emergency Contact Phone
*
(###)
###
####
Emergency Contact Alternative Phone
*
(###)
###
####
List any medical conditions/allergies
*
List any medical conditions or allergies. "None" if Not Applicable.
Player's Physician
*
First Name
Last Name
Physician's phone
*
(###)
###
####
Insurance plan
*
Player medical number
*
Primary Guardian's Name
*
First Name
Last Name
Primary Guardian Home Address
*
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Relationship to player
*
Mother
Father
Legal/Other
Guardian gender
*
Female
Male
Mobile phone
*
(###)
###
####
Home phone
*
(###)
###
####
Work phone
(###)
###
####
Email
*
Primary Guardian Interest
*
ABV is a registered 501(c)(3) non-profit and depends on parental support to keep costs down. Please indicate any activities with which this parent/guardian would be interested in participating.
Secondary Guardian's Name
First Name
Last Name
Address same as Primary Guardian?
Yes
No
Secondary Guardian Address
Please complete if Secondary Guardian's address is different.
Address 1
Address 2
City
State/Province
Zip/Postal Code
Country
Relationship to player
Father
Mother
Legal/Other
Guardian gender
Male
Female
Mobile phone
(###)
###
####
Home phone
(###)
###
####
Work phone
(###)
###
####
Email
Secondary Guardian Interest
ABV is a registered 501(c)(3) non-profit and depends on parental support to keep costs down. Please indicate any activities with which this parent/guardian would be interested in participating.
Comments
Please add additional comments here:
Medical and Liability Release Signature
*
I, the parent/legal guardian of the above named player, a minor, agree that I and the player will abide by the rules and regulations of the Albany Berkeley Volleyball Club, Inc. (ABV) and its affiliated organizations. I, for myself and the player and our respective heirs, administrators and successors, intending to be legally bound, hereby release and indemnify the ABV and its affiliates, the owners and operators of the facilities used for the programs, and their respective directors, officers, employees, agents and representatives from and against all claims, liabilities, damages or causes of action arising out of or in connection with the player's participation in the Programs including, without limitation, player's transportation to/from any Program, which transportation is hereby authorized. I further grant the ABV the right to use player's name, picture and/or likeness in printed, broadcast and other material concerning the Programs provided such use is related to the player's status as a participant in the Programs.
As the parent/legal guardian of the above-named player, I hereby give consent for emergency medical care prescribed by a duly licensed Doctor of Medicine or Doctor of Dentistry. This care may be given under whatever conditions are necessary to preserve the life, limb or well-being of my dependent.
Entering your name below and submitting this form constitutes your electronic signature and full acceptance of this release & waiver.
First Name
Last Name
Electronic Signature Date
*
MM
DD
YYYY
