General Practice, Solo & Small Firm DivisionMagazine
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Authorization & Waiver by Parent(s) or Legal Guardian(s) of Minor ChildEach of the undersigned parent(s) or legal guardian(s) of the minor child named below states as follows:I am aware that normal and usual athletic and sports-related activities have certain inherent risks and may cause injury to participants. However, I want my child to participate in ______________ CLUB (the “Club”) sponsored lessons, practices, games, exhibitions, tournaments, competitions, and other events (the “Activities”), and I give my unqualified permission and consent for my child to participate in the Activities, subject only to any specific limitations noted below.My child has the necessary skills and is able to participate in all reasonably anticipated aspects of the Activities except as noted below. The nature of the Activities has already been fully disclosed to me, and any brochure, flyer, or announcement relating to the Activities is expressly made a part of this Authorization & Waiver.I, on behalf of my child, hereby indemnify, release, hold harmless, and forever discharge the Club and its agents, employees, officers, directors, affiliates, successors, and assigns, of and from any and all claims, demands, debts, contracts, expenses, causes of action, lawsuits, damages, and liabilities, of every kind and nature, whether known or unknown, in law or equity, that I or my child ever had or may have, arising from or in any way related to my child’s participation in any Activities conducted by, on the premises of, or for the benefit of, the Club; provided, that this waiver of liability does not apply to any acts of gross negligence, or intentional, willful, or wanton misconduct.This Authorization & Waiver is binding upon me, my heirs, executors, legal representatives, successors, and assigns. The provisions of this Authorization & Waiver will continue in full force and effect even after the termination of the Activities conducted by, on the premises of, or for the benefit of, the Club, whether by agreement, by operation of law, or otherwise.This Authorization & Waiver is governed by the laws of the State of ________ and is intended to be as broad and inclusive as is permitted by that law. If any provision of this Authorization & Waiver is held invalid or unenforceable by a court of competent jurisdiction, the remaining provisions will continue to be fully effective.This Authorization & Waiver contains the entire agreement between the parties, and supersedes any prior written or oral agreements between them concerning the subject matter of this Authorization & Waiver. The provisions of this Authorization & Waiver may be waived, altered, amended, or repealed, in whole or in part, only upon the prior written consent of all parties.Any claim or controversy that arises out of or relates to this Authorization & Waiver or the alleged breach of it, and that cannot be settled by the parties, will be settled by submission to the chapter of the American Arbitration Association or similar group nearest to the Club in accordance with its current rules and procedures.In the event I cannot be reached, I authorize and direct any adult Activities sponsor or group leader representing the Club to make emergency medical decisions for my child.Please Print
Name of Child: _______________________________________________________
Medical conditions.My child is subject to the following allergies or medical conditions, and I authorize the Club to disclose such allergies or medical conditions to a physician in the event my child should require emergency medical care (describe allergies or medical conditions with specificity): ______________________________________________________
Prohibited activities.As a result of the medical conditions described above or for other reasons, I do not want my child to engage in any of the following activities (describe with specificity): _____________________________________________________________I am of lawful age and legally competent to sign this Authorization & Waiver. I understand the terms of this Authorization & Waiver and I have willingly signed it as my own free act.Name: Name: _______________________________________Address: Address:______________________________________If the child has two parents or legal guardians, both must fill in the information requested above and sign this Authorization & Waiver below.Signature: Signature: _________________________________________________Dated: Dated: ____________________________________________Accepted on behalf of CLUB:_______________________________________By:_______________________________________________ Dated:__________________
This is a sample form. It may not be appropriate in your state, so check your state’s laws.
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