Adult/minor Participant Waiver printable pdf download

C amp P hone: ( 732)2

The Atlantic Club, Inc.

Summer

Adult/Minor Participant Waiver - 2016

Name ______________________________________________ DOB__________

Home Address __________________________________City State Zip _______________________

Parent/Guardian Name_________________________________ Relationship to Child _____________

Cell Phone # ___________________Work Phone #____________ TAC# ____________

Parent/Guardian Name ___________________________ Relationship to Child _______

Cell Phone # ___________________Work Phone # ___________

Parent E-mail Address ____________________________________________________

The Atlantic Club, Inc. – Insurance Waiver

Fax: 7 32-‐223-‐0916

Adult and Minor Participant Waiver/Release/Assumption of Risk/Agreement

In consideration of participating in any way in the athletics/sports programs, and/or otherwise participating in or attending events or

activities, at The Atlantic Club, Inc. (TAC), the undersigned, both individually and on behalf of any minor for whom the undersigned

is legally responsible:

1. Acknowledges and fully understands that each participant will be engaging in activities that by the inherent nature of the activity

involve a risk of serious injury, including the potential of permanent disability and death, and understands and accepts that severe

social and economic loss may result not only from his or her own actions, inactions, or negligence, as well as from the actions,

inactions or negligence of others, the rules of play, and/or from any equipment in the facility or which is used in the normal course of

such activity.

2. Assumes all of the foregoing risks and accepts responsibility for any injury, disability or death to me and/or my child, as well as any

damages, whether social or economic, arising from participation in an activity at or involving TAC, inclusive of such harm arising

from the conduct of others who are also participating therein. I do not, however, accept responsibility for any injuries or damage to me

and/or my child arising while participating in an activity at TAC which is caused by gross negligence.

3. Represents that I, or my child, am qualified, in good health and in proper physical condition to participate in activity(ies) at TAC

and hereby authorize any representative of TAC, or medical provider to seek medical attention on my behalf, or on behalf of my child,

to ensure my well being, or the well being of my child, without any legal liability whatsoever, inclusive of any responsibility for any

negligent rescue operations.

4. Releases, waives, discharges and covenants not to sue TAC, it’s affiliated clubs, administrators, members, directors, agents,

coaches, referees, and/or other employees of TAC, other participants, sponsoring agencies, sponsors, advertisers, owners and

lessons/lessees of the premises used to conduct the event or activity in which I, or the minor participant for whom I am responsible,

participate (all of which are hereinafter referred

to as “releases”), from any and all liability to each of the undersigned, his or her heirs and the next of kin, for any and all claims,

demands, losses or damages on account of any injury, including death or damage to property, caused or alleged to have been caused,

in whole or in part, by the releases or otherwise. I so agree independently on behalf of myself as to any claims I may have as a

participant/spectator and/or as the parent or legal guardian of the subject minor/child, and separately on behalf of the subject

minor/child.

5. Hereby authorizes the use in any promotional materials of any photograph taken of me, or my child, while participating in any

activity at TAC.

6. Agrees that all disputes arising from an injury or claim whatsoever at, or relating to, TAC shall be resolved by mandatory

arbitration.

I/WE HAVE READ THE ABOVE AGREEMENT AND UNDERSTAND THAT I/WE GIVE UP CERTAIN RIGHTS

BY VOLUNTARILY SIGNING IT AND I/WE NEVERTHELESS DO SO.

Signature of Parent, Guardian or Adult Participant: ______________________________ Date _______

Printed Name of Parent, Guardian or Adult Participant:_______________________________________

Student Signature:

_______________________________________________ Date _______

Atlantic Club Representative: _______________________________________________ Date _______

Adult/minor Participant Waiver

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