Release Of Liability And Assumption Of Risk Agreement (Minor)
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42929 Richardson Dr.
Auburn, Ca. 95603
916.652.2422
CHILD’S NAME________________________________________ DATE OF BIRTH ____________ AGE ______ Male___ Female___
ETHNICITY:
African American
Caucasian
Latino
Pacific-Islander
American Indian
East Indian
Asian
ADDRESS__________________________________________________________________________________________________
STREET
CITY
ZIP CODE
HOME PHONE_______________________________
SCHOOL CURRENTLY ATTENDING__________________________________________________________________________
PARENTS/GUARDIAN_____________________________________________________________________________________
WORK NAME & ADDRESS__________________________________________________________________________
WORK
PHONE_________________________________________________________CELL:____________________________
E-MAIL ADDRESS:____________________________________________________
Yearly fees are $25 (one complete calendar year from payment). I understand that no refunds will be issued after membership approval. I
will be responsible for transporting my child to the PSAL facility.
If “yes,” what is your annual income and number in household:
Do you need the membership fees waived: Yes / No
PARENTAL CONSENT, INSURANCE NOTIFICATION, AND MEDICAL TREATMENT AUTHORIZATION
I/we, the parents/guardians of the above names candidate for membership in PLACER SHERIFF ACTIVITIES LEAUGE (PSAL), hereby give my/our
approval to his/her participation in any and all PSAL activities during the current season. I/we do hereby assume all risks and hazards incidental to such
participation including transportation to and from activities. I/we do hereby waive, release, absolve, indemnify and agree to hold harmless, the County of
Placer, PSAL, the respective sanctioning associations, organizations, or leagues and the organizers, sponsors, supervisors, participants and persons
transporting my/our child to and from activities, for claims arising out of injury to my/our child.
PSAL has group accident insurance coverage for medical and hospital expenses, with a deductible for each accident. The insurance is secondary when
there is any other valid and collectible insurance provided by parent/guardian. Limited coverage is provided for any one accident with limited dental
coverage for sound, natural teeth. A copy of the policy is available for inspection at the PSAL office. In signing the foregoing release, I/we acknowledge
that: (1) any claim for medical service which arises out of an injury must be reported to a PSAL league official within thirty (30) days of the date of injury; (2)
I/we have read the forgoing release, understand it and signed it voluntarily. I/we further understand that any registration fee or other sums paid does not
constitute a direct premium payment for insurance.
Do you have HEALTH/GROUP Medical Insurance: YES ___ NO ___
CARRIER:_______________________________ PLAN #____________________ or MEDICAL#_____________________________
In the event of injury to my/our child, ______________________________, I/we hereby grant authority to a qualified physician to render such medical
treatment as said physician deems necessary under the circumstances. I/we, the Parents/Guardian of the above names PSAL Candidate have read and
understand the above Parental Consent, Insurance Information Clause, and Medical Treatment Authorization. By signing this registration form, I/we grant
permission for my/our child to participate in all officially recognized PSAL activities.
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