Gender *

Female

Male

Birth Date *

MM

DD

YYYY

Parent 1 Phone *

(###)

###

####

Will Parent 1 Coach? *

Yes, Head Coach

Yes, Assistant Coach

No Thank You

Parent 2 Phone

(###)

###

####

Will Parent 2 Coach?

Yes, Head Coach

Yes, Assistant Coach

No Thank You

Release and Indemnification *

In playing at PENN Athletics Club of Bucks County, participant understands that he/she attending the programs and using PENN Athletics Club of Bucks County and the facilities does so at his/her own risk. PENN Athletics Club of Bucks County and its owners, employees or agents, shall not be liable for any damage whatsoever arising from any personal injury or property loss sustained by participant with his/her family in or about any programs on the premises. Participants and parents assume full responsibility for all injuries and damages which occur in or about any programs on the premises, He/She does hereby fully and forever release discharged hold harmless PENN Athletics Club of Bucks County, all associated facilities and its owner, employees, and agents from any and all claims, demands, damages or rights of action, present or future resulting from any person’s participation in any programs or use of the facility. In addition, he/she agree(s) to follow the rules of conduct and play set by PENN Athletics Club of Bucks County. Failure to do so may result in suspension from participation. Consent: I the undersigned parent or guardian/participant do hereby grant authority to the staff at PENN Athletics Club of Bucks County to render a judgement concerning medical assistance or hospital care in the event of an accident or illness during my absence. I do hereby authorize PENN Athletics Club of Bucks County and its assigns to utilize any and all photographs, pictures or other likeness of me or anyone assigned guardianship to me, as they deem appropriate in its promotional materials or team films.

I have read and agree to all terms and conditions above.