Clinic/Lesson Registration & Waiver Form
Participant Information:
Athletes
Name: _________________________ Parent Name:________________________
Address:
_____________________________City__________________Zip_____________
Phone:
________________ Parent Cell or Emergency Contact: ______________________
School:
___________________ Grade in fall: _____ B-day: ______
Email Address: ________________________@ _______________________________
Date(s) of
Clinic/Lessons__________________________________________________
Amount
Due:________________ Check
#:____________ Date Paid:_____________
Waiver:
I grant
permission for clinic photos (including my daughter) to be posted on the Illinois
Performance Volleyball, Inc. (www.ipvbc.com),
Elite Sports Complex (www.elitesportscomplex.com)
and/or Team Connection (www.teamconnection.com) website: Yes No
(please circle one)
I grant
Illinois Performance Volleyball, Inc. (IPV) permission to contact me about
future clinics, lessons, volleyball conditioning or tryouts: Yes No
(please circle one)
I hereby
grant permission for my daughter _______________________________, to attend clinics/lessons
offered by Illinois Performance Volleyball, Inc. My daughter has no medical
condition that would interfere with her participation in the clinic. I release
the clinic instructors, clinic facility (Elite Sports Complex,
Parent
Signature: _____________________________________ Date: ______________
If, during
the course of my daughter’s/son’s activities in volleyball, she should become
ill or sustain an injury, I do authorize
the Illinois Performance Volleyball, Inc. staff to obtain emergency
medical/dental care. I will assume financial responsibility for the bills
incurred through my insurance company.
Parent
Signature: _____________________________________ Date: ______________
I do not authorize emergency medical/dental
car for my daughter/son.
Parent Signature:
_____________________________________ Date: ______________