Olympic Peninsula Sports Union- Youth Team

Player’s Name: (the "Player")

1. The Player, and his custodial parent(s) and/or legal guardian(s) (together referred to as the "Undersigned"), hereby consent to the Player’s participation in Rugby Union Football with the Youth Team (the "Team") of the Olympic Peninsula Sports Union. The Undersigned understand and agree that participation includes, but is not limited to, practice sessions, games, meetings, functions, parties, fund raising, and the like, and transportation to and from these activities. The Undersigned further understand and agree that transportation will generally be via automobiles and that the drivers will include adults, other Players, and fellow students. The Undersigned understand there is the potential for some drivers to be underinsured, or uninsured and the Undersigned agree to supplement their insurance to provide for sufficient underinsured or uninsured coverage to compensate for any losses resulting from injury or death in connection with a transportation mishap and the Undersigned otherwise waive claims against any driver beyond his or her insurance coverage as well as against any Olympic Peninsula Sports Union Coach and staff and against the Pacific Northwest Rugby Football Union.

2. The Undersigned understand and agree that the Team is not sponsored by any school within any of the Kitsap County School districts, and as such, these institutions and their administrators and officials are not responsible or liable for injury, sickness, disability, paralysis, or death that may result from the Player’s participation with the Team and all claims against said entities and individuals are waived.

3. The Undersigned understand that there are no salaried coaches or administrators assisting the Team. They are all volunteers. Per the requirements of the Western Washington Youth Rugby Association, all head coaches are certified at a minimum of level 1 by USA Rugby.

4. The Undersigned understand that Players on the Team may include individuals 19 year of age and under, male and female, and that the Team will not only compete against other youth, but also, under controlled circumstances, against adult or college age Teams. The Player agrees to provide the Team with proof of age with a copy of identification with a photograph.

5. The Undersigned understand that Rugby Football is a physical full contact sport with the possibility of injury, minor or major, always present. The Undersigned hereby accept the risks that accompany participation in Rugby Football. The Undersigned agree that they will not hold the Team coaching staff and the Pacific Northwest Rugby Union and its officials and administrators responsible for injury, sickness, disability, paralysis, or death that may result from participation with the Team and all claims resulting from such participation are waived. As such

RELEASE AND WAIVER OF LIABILITY: IN CONSIDERATION OF THE PLAYER’S RIGHT TO PARTICIPATE, THE UNDERSIGNED HEREBY RELEASE, DISCHARGE AND COVENANT NOT TO SUE the coaches, officials, and/or administrators of the Team, the Western Washington Youth Rugby Association, the Pacific Northwest Rugby Football Union, all schools and districts within Kitsap County, and sponsors and workers. THE UNDERSIGNED AGREE THAT THIS RELEASE IS BINDING AND EFFECTIVE AS TO THEMSELVES AS WELL AS TO THEIR PERSONAL REPRESENTATIVES, ASSIGNS, HEIRS, AND NEXT OF KIN AND THAT IT APPLIES TO ANY AND ALL LOSS OR DAMAGE CLAIMED ON ACCOUNT OF INJURY, DISABILITY OR DEATH, WHETHER CAUSED BY THE NEGLIGENCE OF THE ABOVE REFERRED TO ENTITIES, ORGANIZATIONS OR INDIVIDUALS OR OTHERWISE.

The Undersigned understand that by signing this release they are giving up substantial rights they would otherwise have to recover damages for losses and they agree that they are doing so voluntarily and without inducement, threat, or duress. The Undersigned agree that they had the opportunity to seek legal advice before signing this release and have either done so, or have voluntarily elected not to and waive this opportunity.

6. The Undersigned understand that there may not be a trainer at the Team’s games or practice session.

7. The Undersigned understand and agree that the Player will be bound by the Team Code of Conduct while a member of the Team.

8. The Undersigned understand and agree to be solely responsible for the following:

a. To see that the Player has had a physical to determine that he/she is able and fit to play Rugby football

b. To see that the Player has appropriate medical insurance and has done the following:

1. Completed and signed the authorization to consent to medical treatment

2. Provided the Team with proof of insurance

c. To see that the Player wears a mouth piece during all practices and games

d. To see that the Player abides by all Teams rules and instructions

e. To see that the Player does not allow rugby to interfere with school requirements

9. The Undersigned agree to accept all responsibility, including medical and financial, for participation, to pay the annual fee of $30.00 per Player that covers registration, union dues, field and equipment, training aids, etc. The Undersigned understand that each Player must play in a regulation uniform that consists of a jersey, shorts, socks, and approved shoes; that a Player will wear the Team owned jersey and will provide his/her own black rugby shorts and all black over the calf socks.

We have read, understand, and agree to the information and waiver and release of liability as set forth above:

(X) Date:

Player

(X) Date:

Custodial Parent/Legal Guardian

(X) Date:

Custodial Parent/Legal Guardian

I (we) , and , of the city of

, in the county of , Washington do hereby state

that I am (we are) the natural parent(s) (legal guardian(s)) having legal custody of

, a minor, age , born , 19 , who resides with me (us) at

In connection with my (our) child’s participation on the Youth Team of the Olympic Peninsula Sports Union, I (we) authorize the Olympic Peninsula Sports Union to consent to any X-ray examination, any anesthetic, medical or surgical diagnosis or treatment and hospital care which is deemed advisable by, and to be rendered under, the general or special supervision of any physician or surgeon licensed under the provisions of the Medicine Practice Act, whether such diagnosis or treatment is rendered at the office of the physician, or at a hospital. It is understood that this authorization is given in advance of any specific diagnosis, treatment, or hospital care being required, and is being given to provide the Olympic Peninsula Sports Union the ability to give specific consent to any and all such diagnosis, treatment, or hospital care with the aforementioned physician in the exercise of his best judgment may deem advisable. This consent is given with the caveat that the need for treatment is immediate and I (we) am not available. I (we) understand that I (we) assume all liabilities and expenses for the above. I (we) waive all claims against the above referred to adult, physicians, hospitals and their employees, ambulatory care, etc., in connection with the decision for immediate care.

This authorization is only valid from 03 Jan. 99 to 31 Dec. inclusive.

The following is provided: Home phone: , Work Phone:

Name of Primary Caregiver/Phone #

Medical Alert: Allergies: , Medications:

Previous Injuries/Illnesses/Surgery:

Current Physical Condition:

Insurance: Provider: , Policy/ID #:

Address: , Phone #:

Name of Policyholder:

In case of injury, should the youth player be sent to nearest major medical facility, or to a facility covered specially by the

insurance provider? : major medical facility, HMO (or military for dependents) facility, Coach

chooses based on best interest of youth player.

Alternate point of contact:

Name , Phone #:

, Date:

Parent/Legal Guardian

, Date:

Parent/Legal Guardian

**Non-minors and emancipated minors must still fill out this form and sign for themselves.