SAND
VOLLEYBALL
04.24.17
MONDAY
NIGHTS
THURSDAY
NIGHTS
Rec 6v6 - $150 Per Team
Comp 4v4 - $100 Per Team
215 SW A St.
Bentonville, AR 72712
479.464.7275
1101 SW Citizen's Cir.
Bentonville, AR 72712
479.696.0201
2017 Adult Sand Volleyball
Competitive 4v4
TEAM NAME
CAPTAIN'S NAME
ADDRESS
PHONE NUMBER
CITY
EMAIL
STATE, ZIP
Recreational 6v6
Team Roster
NAME
DATE OF BIRTH
EMAIL ADDRESS
SHIRT SIZE
1
2
3
4
5
6
7
8
PARTICIPATION WAIVER: By signing this form, I assume all risks and hazards directly related to and incidental to participation in the City
of Bentonville Parks and Recreation Adult Kickball and the Ozark Volleyball Club. I hereby waive, release, absolve, indemnify and agree to
hold harmless the City of Bentonville, Ozark Volleyball Club, the sponsors, supervisors and participants for any claim arising out of my
injury.*Team Captain is responsible for informing players of participation waiver. Team Captains signature signies that all team members
are aware of and accept participation waiver.
RELEASE OF USE FOR IMAGE OR LIKENESS: I hereby grant my consent and full release to the City of Bentonville Parks and
Recreation, and its successors, to use any video, photographs, and/or motion picture film produced during my participation in approved
recreational activities, to promote and publicize the public recreation opportunities offered by the City of Bentonville Parks and Recreation
Department; and furthermore, I hereby consent that such videos, photographers, or films together with any plates, tapes, negatives, or other
storage media from which they are made, is and shall remain the property of the City of Bentonville Parks and Recreation Department, and
that the Parks and Recreation Department retains the exclusive right to duplicate and reproduce such videos, photographs, or film
recordings from said plates, tapes, negatives, or other storage media free and clear of any claim whatsoever on my part.
DATE
OFFICE USE
CAPTAIN'S SIGNATURE
AMOUNT
DATE
RECEIPT #
METHOD
CHECK #
RECEIVED BY