Gillam-Grant Dodgeball League Team Roster
January 28, February 4, 11, 18, & 25 $175/team
Please complete with all team member names and information (ALL SECTIONS!), including each players signature.
Form must be returned to Gillam-Grant by January 13th, 2017.
TEAM NAME: _____________________________________
LIABILITY WAIVER: Please read this information carefully and be aware that signing up and participating in this program/activity, you will be expressly assuming
the risk and liability and waiving and releasing all claims for injuries, damages or loss which you or your minor ward might sustain as a result of participating in any
and all activities connected with and associated with this program/activity including transportation services, when provided.
I recognize and acknowledge that there are certain risks of physical injury to participants in this program, and I voluntarily agree to assume the full risk of any
injuries, damages or loss, regardless of the severity, that my minor child/ward or I may sustain as a result of participating in any and all activities connected with or
associated with this program/activity. I further agree to waive and relinquish all claims my minor child/ward or may have (or accrue to me or my child/ward) as a
result of participating in this program/activity against Gillam-Grant Community Center and the Byron-Bergen Central School District, including their officials,
agents, volunteers, employees, and sponsors.
I do hereby fully release and forever discharge the Gillam-Grant Community Center and the Byron-Bergen central school District from any claims for injuries,
damages or loss that my minor child/ward or I may have, or which may accrue to me or my minor child/ward and arising out of, connected with, or in any way
associated with this program/activity.
PLAYER 1:
NAME:_________________________________________________________________________________________________
ADDRESS: ________________________________________________________CITY_________________________________
CELL PHONE:_______________________________________EMAIL:______________________________________________
Signature for Waiver:_____________________________________________________ Date:___________________________
PLAYER 2:
NAME:_________________________________________________________________________________________________
ADDRESS: ________________________________________________________CITY_________________________________
CELL PHONE:_______________________________________EMAIL:______________________________________________
Signature for Waiver:_____________________________________________________ Date:___________________________
PLAYER 3:
NAME:_________________________________________________________________________________________________
ADDRESS: ________________________________________________________CITY_________________________________
CELL PHONE:_______________________________________EMAIL:______________________________________________
Signature for Waiver:_____________________________________________________ Date:___________________________
PLAYER 4:
NAME:_________________________________________________________________________________________________
ADDRESS: ________________________________________________________CITY_________________________________
CELL PHONE:_______________________________________EMAIL:______________________________________________
Signature for Waiver:_____________________________________________________ Date:___________________________
PLAYER 5:
NAME:_________________________________________________________________________________________________
ADDRESS: ________________________________________________________CITY_________________________________
CELL PHONE:_______________________________________EMAIL:______________________________________________
Signature for Waiver:_____________________________________________________ Date:___________________________
PLAYER 6:
NAME:_________________________________________________________________________________________________
ADDRESS: ________________________________________________________CITY_________________________________
CELL PHONE:_______________________________________EMAIL:______________________________________________
Signature for Waiver:_____________________________________________________ Date:___________________________
PLAYER 7:
NAME:_________________________________________________________________________________________________
ADDRESS: ________________________________________________________CITY_________________________________
CELL PHONE:_______________________________________EMAIL:______________________________________________
Signature for Waiver:_____________________________________________________ Date:___________________________
PLAYER 8:
NAME:_________________________________________________________________________________________________
ADDRESS: ________________________________________________________CITY_________________________________
CELL PHONE:_______________________________________EMAIL:______________________________________________
Signature for Waiver:_____________________________________________________ Date:___________________________
PLAYER 9:
NAME:_________________________________________________________________________________________________
ADDRESS: ________________________________________________________CITY_________________________________
CELL PHONE:_______________________________________EMAIL:______________________________________________
Signature for Waiver:_____________________________________________________ Date:___________________________
PLAYER 10:
NAME:_________________________________________________________________________________________________
ADDRESS: ________________________________________________________CITY_________________________________
CELL PHONE:_______________________________________EMAIL:______________________________________________
Signature for Waiver:_____________________________________________________ Date:___________________________
DO NOT COMPLETE THIS SECTION. OFFICE USE ONLY.
USE FOR ALTERNATE IN CASE OF MEDICAL NEED ONLY
NAME:_________________________________________________________________________________________________
ADDRESS: ________________________________________________________CITY_________________________________
CELL PHONE:_______________________________________EMAIL:______________________________________________
Signature for Waiver:_____________________________________________________ Date:___________________________