Risk Acknowledgement and Consent to Participate Form

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SYBA – Brookfield East Jr. Spartans Baseball    

Risk Acknowledgement and Consent to Participate Form

Participant’s  Name:  ________________________________________  DOB:  ____________     Address:  ____________________________________________________________________     1)  Parent/Guardian  __________________________________________     Parent/Guardian  Address_______________________________________     Home  Phone:  ________________  Work  Phone:  _____________  Cell  Phone:  ______________     2)  Parent/Guardian:  __________________________________________     Parent/Guardian  Address:  _____________________________________________________     Home  Phone:  ________________  Work  Phone:  _____________  Cell  Phone:  ______________       As  the  parent/legal  guardian  of  _______________________  (player’s  name),  I  hereby  certify  that  to  the  best  of  my   knowledge  the  above-­‐named  player  is  in  good  health,  with  no  apparent  illness,  physical  or  mental  disabilities,   or  other  limitations  which  would  preclude  his  participation  in  baseball  with  the  SYBA  Jr.  Spartans  baseball   program.    In  addition,  I  hereby  do  attest  that  this  child  has  had  a  physical  examination  within  the  last  12-­‐ months  by  a  licensed  physician  and  has  received  permission  from  this  physician  to  participate  in  the  SYBA  Jr.   Spartans  baseball  program.     Furthermore,  I/we  realize  that  there  are  numerous  risks  involved  in  participating  in  baseball.  These  risks   could  involve  (but  are  not  limited  to):  sprains,  contusions,  broken  bones,  lacerations,  concussions,  permanent   disability,  internal  injuries,  paralysis  and  possibly  death.  These  risks  could  impair  my/our  child’s  future   abilities  to  earn  a  living,  engage  in  business,  social,  and  recreational  activities  and  to  generally  enjoy  life.  I/We   have  been  informed  about  the  various  risks  associated  with  our  child’s  participation  in  the  baseball  program   and  the  potential  injuries  that  may  occur.     As  a  condition  of  our  child’s  voluntary  participation  in  the  above  mentioned  sport,  I/we  agree  to  accept  all  the   previously  mentioned  risks  as  a  condition  of  my/our  child’s  participation,  and  do  hereby  forever  release  and   discharge  SYBA,  and  all  its  officers  and  coaches  from  all  liabilities,  claims,  causes  of  action,  demands,   damages,  costs  of  fees,  which  the  undersigned  may  now  or  hereafter  have  for  accident  or  injury  which  may   occur  to  my  child  as  a  result  of  his  participation.         _____________________________________________  __________________________   Signature  Parent/Legal  Guardian           Date       _____________________________________________  __________________________   Signature  Parent/Legal  Guardian           Date