Player Information
Name:	Age:		Birth Date:		Weight:
Address:	City:			Grade: (coming year)
Father’s Name:		Mother’s Name:
Home Phone:		Work Phone:
Emergency Contact:		Emergency Phone:
Doctor’s Name:		Doctor’s Phone:

Medical History
Check any of the following that apply.
	o	Suffers from Asthma
	o	Presently taking any medications
	o	Allergic to medicines, food, bee stings, etc.
	o	Wears glasses, contact lenses, hearing aid, dentures, etc.
	o	History of any dental problems
	o	Any current or on-going medical problems
	o	Any serious or significant past illness
	o	Any past injuries requiring medical help
	o	Any sports related injuries
	o	Any known deformities (such as Scoliosis, heart problems, one kidney, etc.)
	o	Any serious family illness (Diabetes, heart, bleeding disorders, etc.)
	o	Any past or present problems with exercise
	o	Any use of tobacco, steroids, or alcohol
	o	Has had physician placed restrictions on activities
	o	Any past or present emotional problems that require special attention / concern of a coach
Check if your child has had problems with any of the following areas of the body.
	o	Skin	o	Neck	o	Head	o	Eyes	o	Ears
	o	Nose	o	Mouth	o	Throat	o	Lungs	o	Heart
	o	Abdomen	o	Back	o	Urination	o	Bowel	o	Genital
	o	Shoulders	o	Legs/Hips	o	Arm/Hand	o	Mental	o	Muscles
Please provide an explanation for any of the items above that you checked or answered yes to.

PLEASE READ CAREFULLY BEFORE SIGNING THIS ACKNOWLEDGEMENT, WAIVER AND RELEASE FROM LIABILITY (AWRL)

1. (AWRL) I acknowledge that football or any sporting event is a test of a person's physical and mental limits and carries with it the potential for serious injury or property loss. With full knowledge of the activities involved, I hereby assume the risks of my child or minor for whom I am acting as guardian (hereinafter my “child”), participating in the Bridgman Rocket Football Program. In consideration of permission to participate in the Bridgman Rocket Football Program and other adequate sufficient consideration, I hereby take the following action for my child, myself, (my and child’s executors, administrators, heirs, next of kin, successors and assigns): a) I WAIVE, RELEASE, AND DISCHARGE from any and all claims or liabilities for death or personal injury or damages of any kind, which arise out of or relate to my participation in, or traveling to and from the event, THE FOLLOWING PERSONS OR ENTITIES: the Bridgman Rocket Football Program, the coaches, any volunteers, any sponsors, the web site owners and developers, the city of Bridgman, the program directors, or any of it's employees, the Bridgman High School, the event coordinators, participants; Coaches; and the officers, directors, employees, representatives and agents of any of the above (collectively, the Bridgman Rocket Football Program Entities); b) I AGREE NOT TO SUE any of the persons or entities mentioned above for any of the claims or liabilities that I have waived for myself or my child, released or discharged herein; and c) I INDEMNIFY AND HOLD HARMLESS the persons and/or entities mentioned above from any claims made or liabilities assessed against them. I agree to indemnify and hold each of the Bridgman Rocket Football Program Entities and its officers and employees harmless from any claim or demand, including attorneys' fees, made by any third party due to or arising out of my child’s participation in the Bridgman Rocket Football Program or the violation of any term of this Liability Waiver or the use of the Bridgman Rocket Football Program by you. I understand that Rocket Football is a contact sport from which injury may arise. I agree that if an injury should arise or occur, that I or my medical insurance will cover all costs, medical and otherwise.

2. (AWRL) Applicable Law; Consent to Jurisdiction. You agree that exclusive jurisdiction for any dispute with the Bridgman Rocket Football Program resides in the courts of the State of Michigan. Exclusive jurisdiction and venue shall be in the Berrien County, Michigan courts. and you further agree and expressly consent to the exercise of personal jurisdiction in the courts of the State of Michigan, County of Berrien, in connection with any dispute including any claim involving the Bridgman Rocket Football Program or its Entities, affiliates, subsidiaries, employees, contractors, officers, directors, telecommunication providers and content providers, the coaches, any volunteers, any sponsors, the web site owners and developers, the city of Bridgman, (collectively, the Bridgman Rocket Football Program Entities).

3. (AWRL) Severability. If any provision of this Liability Waiver shall be unlawful, void, or for any reason unenforceable, then that provision shall be deemed severable from this Liability Waiver and shall not affect the validity and enforceability of any remaining provisions.

I acknowledge that I have read this document, and understand its content.

PARENT/GUARDIAN SIGNATURE ________________________________

The undersigned (parent/guardian) the parent and/or guardian of___________________________________(print minor's name) hereby acknowledges that he/she has executed the foregoing AWRL for and on behalf of the minor named herein.

As the natural or legal guardian of such minor, I hereby bind myself, the minor, and our executors administration, heirs, next of kin, successors, and assigns to the terms of the foregoing AWRL. I represent that I have the legal capacity and authority to act for and on behalf of the minor named herein, and I agree to indemnify and hold harmless the persons or entities mentioned in the foregoing AWRL for any expenses incurred, claims made, or liabilities assessed against them, as a result of any insufficiency of my legal capacity or authority to act for and on behalf of my child in the execution of the foregoing AWRL or in the execution of this consent and authorization for medical treatment.

I understand that Rocket Football is a contact sport from which injury may arise. I agree that if an injury should arise or occur, that I or my medical insurance will cover all costs, medical and otherwise.

I hereby authorize any licensed physician, emergency medical technician, hospital or other medical or health care facility ('Medical Provider') to treat the minor named herein for the purpose of attempting to treat or relieve any injuries received by said minor arising out of or relating to any event or practice sanctioned by the Bridgman Rocket Football Program. I authorize any such Medical Provider to perform all procedures deemed medically advisable by the Medical Provider in attempting to treat or relieve any such injuries and any related conditions of said minor that may be encountered during the course of attempting to treat or relieve such injuries. I consent to the administration of anesthesia as deemed advisable during the course of such treatment. I realize and appreciate that there is a possibility of complications and unforeseen consequences in any medical treatment, and I assume any such risk for and on behalf of said minor and myself. I acknowledge that no warranty is being made as to the results of any medical treatment. NOTE: Parent/Guardian must also sign AWRL above.

PARENT/GUARDIAN NAME (print): _______________________________ RELATIONSHIP TO MINOR: ______________

PARENT/GUARDIAN SIGNATURE: ________________________________ Date Signed: ___________________