Trojan Water Polo Club
Online Registration
Medical Release Form
Name:_________________________________________________
Phone (
For Official Use Only
Received By:
Date: ___/___/___
)________________________________________
Birth Date :____________________________________________
Gender: Female / Male
Please print two copies of this page. Keep one copy for your records and bring the other copy with you to your first practice.
EMERGENCY MEDICAL AUTHORIZATION: (Agent: Authorized Agent of TROJAN Water Polo Club)
I/We, parent(s)/person(s) having legal custody/legal guardian of a minor, do hereby authorize medical, dental or surgical diagnosis or
treatment, and hospital care which is deemed advisable by, and is to be rendered under the general or on the medical staff of any
hospital, whether such diagnosis or treatment is rendered at the office of said physician, dentist or at said hospital. It is understood that
this authorization is given in advance of any special diagnosis, treatment, or hospital care being required but is given to provide authority
to the aforesaid Agent to give specific consent to any; and all such diagnosis, treatment, or hospital care which a physician or dentist
meeting the requirements of this authorization may in the exercise of his/her best judgment deem advisable.
This authorization is given pursuant to the provisions of Sections 6910 and 6550 of the Family Code of California. RELEASE
AGREEMENT: We, the undersigned parent(s) or legal guardian(s) of the undersigned minor (Trojan Water Polo Club Player) for
ourselves and on behalf of the Player, our heirs, assigns and agents acknowledge that participation and/or receiving instruction in water
polo necessarily involves travel, play in adverse weather conditions, physical contact and risk of severe and permanent physical injury.
For myself, and on behalf of the Player, our heirs, assigns and agents, we willingly and voluntarily accept and assume all such risk.
In consideration of accepting the registration and permitting the voluntary participation of the Player in the water polo program of the
TROJAN Water Polo Club (ATROJAN@), for ourselves and in behalf of Player, our heirs, assigns and agents, were hereby release,
discharge and agree to hold harmless TROJAN, its employees, volunteers, officials, sponsors, officers, directors, owners and other
representatives from any and all claims (including, but not limited to personal injury, property damage and wrongful death claims),
demands, costs, expenses and compensation arising out of or in any way related to any physical injury or other damages that may result
from Player participating and/or receiving instruction in any water polo event sponsored and/or operated by TROJAN, including any
physical or other injury caused by the negligence of any person while performing his/her duties at any time.
We understand and agree that this Release will have the effect of releasing, discharging, waiving and forever relinquishing any and all
actions or causes of action that we may have or have had, whether past, present, or future, whether known or unknown, and whether
anticipated or unanticipated by me, arising out of my participation and/or receipt of instruction in water polo. This Release constitutes a
complete release, discharge and waiver of any and all actions or causes of action against TROJAN.
For ourselves and on behalf of the below Player, we further acknowledge that TROJAN is primarily administered by volunteers rather
than paid professionals. For ourselves and on behalf of the below Player, he/she, we voluntarily agree to comply with the stated and
customary terms and conditions for participation and, if he/she or we observe any unusual significant concern in his/her readiness for
participation and/or in the program itself, we will remove him/her from participation and bring such concern to the attention of the nearest
TROJAN official immediately.
ACKNOWLEDGMENT & CONSENT: We acknowledge that we have read this Release Agreement and that we understand the terms,
and understand that we and the Player have given up substantial rights by our signing this Release Agreement and agreeing to these
terms, and we sign this Release Agreement and agree to these terms freely and voluntarily and without inducement for ourselves and on
behalf of the Player.
Parent Signature:_____________________________________ Date _____________
Printed Name:_________________________________________