HomeMy WebLinkAboutICPRD SPORTS ROSTER-----------------------
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FOR O F FICE USE ONLY ____Fee+ ( ____NR x $5) =____ Receipt# ____ Initial: ____
IOWA CITY PARKS RECREATI ON DEPARTMENT
ADU LT SPORT LEAGU E ROST ER
WOMENS [ ] MENS [ ] COREC [ ] SENIOR HIGH [
SPORT: DAY: DIVISION: TEAM NAME:
CAPTAIN : ADDRESS:
CITY/ PHONE
STATE/Z IP: NUMBERS: ~(h~)________(~w~)______~(e_m_a_i~I) __________
PARTICIPANT WAIVER AND RELEASE: I acknowledge that participating in t his activity may be a major test of a person 's physical and mental limits and carries
with it the potential for serious injury, death and/or property loss. I hereby assume, for myself and/or my minor ch ild , all the risks, inherent or otherwise, of
participating in this event. I certif y that I am physically fit, have sufficient training for participation in this activity, and have not been advised otherwise by a qual ified
medical professional. In consideration of my being permitted to participate in this activity, I hereby take action for myself, my spouse, executors, administrators,
heirs, next of kin , successors and assigns, to RELEASE, WAIVE , DISCHARGE, COVENANT NOT TO SUE, INDEMNI FY AND HOLD HARMLESS the City of Iowa
City, Iowa, its officers, agents, employees, and volunteers, from all liab ility t o the und ersigned , my spouse, personal representatives, assigns, heirs, and next of kin
for any and all loss or d amage, and any claim or demands t herefor on accou nt of death, disability, personal injury, property d amage, or property theft, w hether
caused by the negligence of the releasees or otherwise. In the event of injury, I gi ve permission to hospitals, physicians and other care providers to render such
treatment as would be normal and agree to pay the usual charges for such t reatment. I understand that this release applies to any present or future inj uries and that
it bi nds my spouse, dependents, and personal representati ve. I further agree to abide by the rules an d regulations of the Iowa City Parks and Recreation Department.
I h d th· I d d d II f . I . . I ·1 d . h f II k I dIge of .its s 1.grnT1cance.ave rea 1s re ease an un erstan a o its terms. sign 1t vo untan Iy an Wit u now e
PLEASE PRIN T OR TYPE
NAME
WRITTEN
SIG NATURE
HOME
ADDRESS CIT Y Z IP PHONE E-MAIL NR
1.
(captain)
2 .
(co-captain)
3 .
4.
5 .
6 .
7 .
8.
9 .
10.
PARTICIPANT WAIVER AND RELEASE: I acknowledge that participating in this activity may be a major test of a person's physical and mental limits and carries
with it the potential for serious injury, death and/or property loss. I hereby assume , for myself and/or my minor child, all the risks, inherent or otherwise, of
participating in this event. I certify that I am physically fit, have sufficient training for participation in this activity, and have not been advised otherwise by a qualified
medical professional. In consideration of my being permitted to participate in this activity, I hereby take action for myself, my spouse, executors, administrators,
heirs, next of kin , successors and assigns, to RE LEASE, WAIVE , DISCHARGE, COVENANT NOT TO SUE, INDE MNIFY AND HOLD HARMLESS the City of Iowa
City, Iowa, its officers, agents, employees, and volunteers, from all liability to the undersigned, my spouse, personal representatives, assigns, heirs, and next of kin
for any and all loss or damage, and any claim or demands therefor on account of death, disability, personal injury, property damage, or property theft, whether
caused by the negligence of the releasees or otherwise. In the event of inj ury, I g ive permission to hospitals, physicians and other care providers to render such
treatment as would be normal and agree to pay the usual charges for such treatment. I understand that this release applies to any present or future injuries and that
it binds my spouse, dependents, and personal representative. I further agree to abide by the rules and regulations of the Iowa City Parks and Recreation Department.
I h d h" I d d d II f . I . . I ·1 d . hf II k I d f . . Tave rea t 1s re ease an un erstan a o its terms. sign 1t vo untan Iy an Wit LI now e Ige o its s 1grn 1cance.
PLEASE PRINT OR TYPE
NAME
WRITTEN
S IGNATURE
HOME
ADDRESS CITY Z IP
HOME
PHONE EMAIL NR
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
21 .
22.
23.
As captain/manager/coach of ________team, I have this __day of ____, 20_, duly signed the above players and certify that each
player has read and understands the statements on this roster. I also certify that each player's s ignature is in their own handwriting.
Instructions: Print and include written signatures before turning in.
JS 9/01 /09 Signed:___________________
Captain/Manager/Coach