Dayton Juniors Medical Waiver
  DJRS Medical Release, Waiver, and Release of Liability Permission to treat & emergency Information form must be on file in the DJRS office for any athlete not a member of USAV or AAU. 

 This form MUST be filled out completely prior to an athlete’s participation at the DJRS Training Facility. 

BY SIGNING THIS FORM THE PARTICIPANT AND GUARDIAN AFFIRMS HAVING READ IT.   
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Participant Name *
Phone *
Email Address *
Address *
City *
State *
Zip *
The participant named above has my permission to participate in training, competition, events, and activities sponsored by Dayton Juniors Volleyball Club. I approve the leaders who will be in charge of this program. I recognize that the leaders are serving to the best of their ability. I certify that the participant has full medical insurance with the company listed on this document. I also certify that the participant listed above is physically fit to engage in the activities described herein. 

Further, I give permission to DJRS to treat the participant or arrange for medical care or treatment for the participant in any situation deemed reasonably necessary by the DJRS staff member. If circumstances permit, DJRS shall attempt to communicate first via telephone using the emergency contacts for the participant. 

In the event neither emergency contact can be reached; or if the urgency of the situation requires immediate attention without prior telephone contact, DJRS may arrange for medical treatment for the participant at the expense of the parent or guarding signing this form.
Primary Emergency Contact
Name *
Relationship *
Phone *
Secondary Emergency Contact
Name *
Relationship *
Phone *
Insurance Company *
Policy Number *
In order to seek appropriate medical care or treatment of participant, please disclose any important health related information:
Allergies/Heart Issues/Other *
Parent Guardian Signature (Type Name) *
Relationship *
Date *
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Release of Liability
  As guardian of the participant named in this document, I do for both of participant’s parents, for participant and participant’s heirs and successors, release DJRS Volleyball Club and any of its agents or representatives (all of the foregoing collectively “DJRS”)from all claims arising out of or connection with participation in any DJRS insured club program or event. I provide this release because I am mindful that athletics, physical training, and competition can be a dangerous undertaking regardless of how careful or prudent any person, organization or facility might be. 

As participant, I agree that: 

1. The risk of injury from the activities involved in this program is significant, including the potential for permanent paralysis and death, and while particular rules, equipment, and personal discipline may reduce this risk, the risk of serious injury does exist. 

2. I knowingly and freely assume all such risks, both known and unknown, even if arising from the negligence of the releases, but not gross negligence of the releases, or others, and assume full responsibility for may participation. 

3. I willingly comply with the stated and customary terms and conditions for participation. If however I observe any unusual significant hazard during my presence or participation, I will remove myself from participation and bring such to the attention of the nearest DJRS staff member immediately. 

4. I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, hereby release, indemnify, and hold harmless the Dayton Juniors Volleyball Club, their officers, officials, agents and/or employees, other participants, sponsoring agencies, sponsors, advertisers, and if applicable, owners and lessors of premises used to conduct the event (releases), with respect to any and all injury, disability, death, or loss or damage to person or property, whether arising from the negligence of the releases or otherwise, to the fullest extent permitted by law. 

I have read this release of liability and assumption of risk agreement, fully understand its terms, understand that I have given up substantial rights by signing it, and sign it freely and voluntarily without any inducement.  
Participant Signature (Type in) *
Age
Date *
MM
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DD
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YYYY
For Parents/Guardians of Participant of Minor Age (Under 18)
  This is to certify that I, as Parent/guardian with legal responsibility for this participant, do consent and agree to her/his release as provided above of all the Releasees, and for myself, my heirs, assigns, and next of kin, I release and agree to indemnify and hold harmless the Releasees from any and all liability incidents to my minor child’s involvement or participation in these programs as provided above, even if arising from the negligence of the releases, to the fullest extent permitted by law  
Parent/Guardian Signature (Type in) *
Date *
MM
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DD
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YYYY
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