I hereby authorize the staff of Sequoia Crush Volleyball Club, the City of Visalia and Stonebrooke Park to act for me according to their best judgment in any emergency requiring medical attention. With full understanding of the potential risk, I hereby waive and release all responsibility to both parties from any and all liability for injuries, illness or lost property. I have no knowledge of any physical impairment that would affect my participation during the training as outlined. By signing below I assume the full risks of participating and confirm that the participant is covered by a personal insurance policy.

Name:___________________________________ Grade:____ Age:____ DOB:________

Address:__________________________ City:________________ Zip:______________

Phone: (        )______________ E-mail:___________________ Referred By:__________

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Signature (Parent or Guardian)                                                      Date

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Signature (Participant)                                                                   Date