Gig Harbor Volleyball Club

Tryout Consent, Release of Liability, and Medical

Authorization

Player Name: _______________________ Date: ______________

This is to certify that I, ______________________, parent or guardian of the player

named above; hereby grant my permission to the Gig Harbor Volleyball Club (GHVC),
GHVC Coaches and/or affiliated GHVC tryout staff, or any member of Harbor Club
Sports (UBI 602895862), to obtain emergency medical care from any
duly licensed Doctor of Medicine, hospital or medical clinic for my child. This
authorization is valid only while the player is away from her legal residence for the
purpose of participating in the GHVC 2009-2010 season tryouts. I give my child
permission to participate in the GHVC 2009-2010 season tryouts held on or about
November 19th, 2009. I, acknowledge that volleyball as any sporting event is an
extreme test of a person’s physical and mental limits and carries with it the potential for
death, serious injury or property loss. With full understanding of the potential risks, I
HEREBY ASSUME THE RISK for participation. Further, I release GHVC, GHVC staff,
members of Harbor Club Sports, and Lighthouse Christian School, from any and all
claims or liabilities for death or personal injury or damages of any kind. I agree not to sue
any of the persons or entities mentioned above for any of the claims or liabilities that
have been waived. I indemnify and hold harmless the persons or entities mentioned
above from any claims made or liabilities assessed against them as a result of my child’s
actions. Light House Christian School is in no way affiliated with Gig Harbor Volleyball
Club or Harbor Club Sports. I also certify that my child is covered by a government
and/or private health and accident insurance plan. I understand I am responsible for all
hospital, laboratory, dental and doctor’s fees. My child is physically fit to participate in
vigorous physical activity.

Parents Name: ________________________________Phone #: ________________

Parent’s Signature: ___________________________________ Date: ____________

Emergency Phone #’s ________________________________________

Insurance Company: _________________________ Policy #: ___________________

ID # ______________________