Gillette Soccer Club
3v3 Summer Program
Medical and Liability Waiver
I understand that by the nature of the activity there is possibility for injury. Knowing and having been informed of the risks associated with the 3v3 Summer Program (“the Program”) participation, and in consideration of my child/ward being allowed to participate in the Program, I hereby agree on behalf of myself, my family members and my child/ward to assume all risks and, further, to waive, release and hold harmless the Gillette Soccer Club and its coaches, the owners and operators of the facilities used for the Program and their respective directors, officers, employees, agents and representatives from and against all claims, liabilities, damages or causes of action arising out of or in connection with the player’s participation in the program including, without limitation, player’s transportation to and from the Program.
I further grant the Gillette Soccer Club the right to use the player’s name, picture and/or likeness in printed, broadcast and other material concerning the Program, provided such use is related to the player’s status as a participant in the Program.
I hereby consent to permit the coach, staff working with the Program to provide emergency first-aid or medical treatment for my child/ward, as necessary, in the event he/she suffers an injury or illness while participating in the Program or on the Program premises. I also understand that all costs are my responsibility and that Gillette Soccer Club does not provide primary insurance coverage for injuries to Program participants.
Name _____________________________________ Name ____________________________________
Parent/Guardian (Please Print) Player (Please Print)
_______________________________ ________ ___________________________ _________
Parent/Guardian Signature (if under 18) Date Player Signature (if over 18) Date
Emergency Contact Information
Contact Name Phone Number