WAIVER / RELEASE FORM
Dedham Pee Wee Football Association, Inc , “DPWFA”
I. PARENTAL CONSENT
I, the parent or legal guardian of , a candidate for a position on one of the “DPWFA” football clinic do hereby grant permission for his / her participations in any, and all team activities.
I give the “DPWFA” permission to post pictures of my child on the “DPWFA” web site, the local newspapers and any other flyers or publications that directly relate to the organization.
*NO I do not agree, please Initial:
III. RELEASE FROM LIABILITY
I agree to assume all risks and hazards incidental to participation in the football clinic. I do hereby waive, release, absolve, indemnify, and agree to hold harmless, American Youth Football, the Eastern Mass American Youth Football & Cheer Conference, “DPWFA”, the officers, directors, sponsors, volunteers, participants, and persons transporting my child to and from any and all team activities, for any claim arising out of an injury to my child, whether the result of negligence or any other cause.
IV. MEDICAL RELEASE
Because your child is involved in an active sport, there may be an occasion when an injury occurs that requires medical treatment and we are unable to contact you.
Participant: Date of Birth:
Parent Name: Home Phone #: Mobile #:
Family Physician: Telephone #:
If Parent or legal guardian cannot be reached, call: Name: Telephone #:
Please list any allergies and medical conditions that should be brought to our attention. Include ANY medication(s) that your child uses regularly:
I hereby grant permission to Dedham Pee Wee Football Association, Inc. to administer first aid, secure proper treatment, and/or hospitalize my (son, daughter, ward) in case of emergency, provided they are unable to communicate with me, and according to their best judgment.
SIGNATURE of Parent or Legal Guardian:
I HEREBY ACKNOWLEDGE BY MY SIGNATURE THAT I HAVE READ, UNDERSTOOD, ACCEPTED, AND AGREED TO THIS DOCUMENT.
SIGNATURE Parent or Legal Guardian Date
Printed Parent or Legal Guardian name
CLINIC USE ONLY