12U Developmental League

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Name of Player

School Attending

Player Birth Date

YYYY

Parent/Guardian Name(s) *

Parent Email *

Address *

Parent/Guardian Phone Number *

The undersigned parent or natural/legal guardian does hereby acknowledge that he/she is aware of the dangers in his/her daughter/son participating in the BHJ 12U Developmental League at Black Hills Works. *

Yes

Said undersigned parent or natural/legal guardian does hereby represent that he/she is in fact, acting in such capacity and agrees on behalf of the participant and his/her executors, administrators, heirs, next of kin, successors and assigns, to waive, release and discharge from any and all liability for participant's death, disability, personal injury, property damage, property theft or actions of any kind which may hereafter accrue to participate and his/her estate, Black Hills Works and the BHJ Coaching Staff. Also, to indemnify and hold harmless Black Hills Works and the coaching staff from and against any and all liabilities and claims made by other individuals or entities as a result of participant's participation or actions during the 12U Developmental League. Lastly, acknowledge that the participant attending the volleyball pre-tryout voluntarily, and all risks from injury or the COVID-19 virus have been made clear and the participant does not have any pre-existing conditions that will increase the likelihood of injuries or illnesses. *

Yes

The undersigned further consents to and authorizes medical treatment to the participant which may be deemed advisable in the event of injury, accident or illness during this 12U Developmental League. This release and waiver shall be construed broadly to provide a release and waiver to the maximum extent permissible under applicable law. *

Yes

I, the undersigned, acknowledge I have read and understand the above 12U Developmental League waiver. Signed parent/guardian name and date: *

Insurance Provider *

Insurance Group Number *

Insurance Policy Number *

Insurance holder signature *

Please type first and last name below with the date.

Parent/Guardian Signature *

Please initial & date stating that you have paid the $400 or will pay after this registration. The player will not be able to play until this form and the fee have been completed. *

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