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Please print and complete the NKSL Waiver Form and mail with the Registration Form and payment to Janet Piccirillo at the address listed below:
Janet Piccirillo 153 Lookout Farm Drive Crestview Hills, KY 41017
PARENTAL WAIVER AND RELEASE FORM
As the parent or legal guardian of the child named below, I hereby give my full consent and approval for my child to participate as a team member in the sport designated below. I understand that there are certain risks of injury inherent in the practice and play of this sport, as well as in traveling and other related activities incidental to my child’s participation, and I am willing to assume these risks on behalf of my child. I hereby certify that my child is fully capable of participating in the designated sport and that my child is healthy and has no physical or mental disabilities or infirmities that would restrict full participation in these activities, except as listed below.
In addition to giving my full consent for my child’s participation, I do hereby waive, release and hold harmless the organization named below, its officers, coaches, sponsors, supervisors and representatives for any injury that may be suffered by my child in the normal course of participation in the designated sport and the activities incidental thereto, whether the result of negligence or any other cause.
___________________________________ _________________ _____________ Name of Child Date of Birth Gender
___________________________________ _________________ _____________ Name of Child Date of Birth Gender
___________________________________ _________________ _____________ Name of Child Date of Birth Gender
___________________________________ _________________ _____________ Name of Child Date of Birth Gender
___________________________________________________________________________ Street Address
___________________________________________________ _______________ City State
Please list any physical limitations (allergies, hearing, sight, etc.) __________________________________________________________________________________
__________________________________________________________________________________
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Designated Sport: Swimming / Diving / Both (circle one)
_____________________________________________ ______________ Parent’s Signature Date
Beechwood Swim Club and the Northern Kentucky Swim League, Inc. Name of Sponsoring Organizations
Remember: Please enclose this consent form, registration form and your check. |