Parent/Guardian Name *

First Name

Last Name

Participant's Name *

First Name

Last Name

Participant's Gender *

Female

Male

Participant's Date of Birth *

MM

DD

YYYY

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone (primary) *

(###)

###

####

Phone 2

(###)

###

####

WAIVER AND DISCLAIMER OF LIABILITY & CONSENT TO MEDICAL CARE *

To persuade the Wabash Valley YIA to accept the registration and permit the participation in YIA sports by the above named individual, I hereby give my consent to agree to release indemnity, and hold harmless the Wabash Valley YIA and Wabash Community Unit School District #348, their officials, coaches,and representatives from any claim arising out of any injury to the above named individual while participating in any YIA sport sanctioned activity or while in transit to or from thereto. I also hold harmless the Wabash Valley YIA and Wabash Community School District #348, their officials, coaches, and representatives from any claims arising out of injuries or conditions caused by or aggravated by my refusal to obtain available medical treatment based on religious or philosophical beliefs.Should the above named individual require medical care for either illness or injury, I give my consent for any appropriate medical treatment by a person certified to perform such acts.

I agree

I disagree