Youth Sports Release of Liability

Student's Name:

Student's Date of Birth: *

Student's Grade:

Please list any medical conditons that could impact your student's health (such as asthma or a heart problem):

Parent:

Address:

Email:

Phone:

Emergency Contact:

Emergency Contact Number:

I hereby consent to allow my son or daughter to participate in YOUR COMPANY NAME HERE Sports Program. I consent to not hold YOUR COMPANY NAME HERE or any of their officers / program volunteers responsible for any injury to my son or daughter. I agree not not pursue any legal action against any employee or volunteer of YOUR COMPANY NAME HERE.

Parent Signature:

Date: