CREEK
WATER POLO

WAIVER AND RELEASE FORM

Every player must have a completed waiver on file.

Please Fill Out the Form Below For your Athlete!

WAIVER AND RELEASE

PARENTS SHOULD FILL OUT THIS FORM FOR UNDER 18 ATHLETES. 18+ ATHLETES SHOULD FILL OUT THEMSELVES.

Player Information

Player Name *(as registered with USA Water Polo)

Player Birthday *

USA Water Polo Number *Must be registered Bronze level or higher: if player does not play with another water polo club, registration should be with Colorado High School Water Polo Association (CO-35306)

Emergency Contact #1

Emergency Contact Name *

Emergency Contact Phone *

Emergency Contact #2 (optional)

Secondary Emergency Contact Name

Secondary Emergency Contact Phone

Medical Information

List Any Medical Conditions *Please list and and all medical conditions player has which may be helpful to coaching staff or critical in the event of illness or injury. Enter "None" if there are none.

List Any AllergiesPlease list and and all allergies, particularly severe allergies, and including allergies to medication.

List Any MedicationsPlease list any medications player may need during practice or games or relevant to medical personnel.

Physician and Insurance (optional)Please provide Primary Care Physician Name and Phone Number, and Insurance Provider Name and Policy Number. These may be helpful if medical treatment becomes necessary.

Release, Waiver, and Acitivity Risk

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Liability Waiver and Release

Creek Polo Inc.

In consideration for being permitted by Creek Polo Inc. (the “Club”) to participate in water polo practices, training sessions, games, tournaments, dryland workouts, and any related activities (“Activities”), I hereby waive, release, and discharge any and all claims for personal injury, death, or property damage that I may suffer, or that may later accrue to me, as a result of my participation in the Activities.

This release is intended to discharge in advance Creek Polo Inc. their officers, directors, owners, employees, volunteers, agents, and representatives from any and all liability arising out of or connected in any way with my participation in the Activities, even if such liability arises from negligence or carelessness on the part of the persons or entities listed above.

I understand that water polo is a contact sport, and that participation in water polo and related training involves inherent risks, including the risk of serious injury or accident, and I voluntarily assume all such risks. This waiver, release, and assumption of risk is binding upon my heirs, executors, administrators, and assigns. I have provided to the Club a medical waiver signed by my physician indicating permission to play this sport.

I agree to indemnify and hold harmless the persons and entities listed above from any loss, liability, damage, cost, or expense that may be incurred as a result of my injury, death, or property damage arising from participation in the Activities.

I understand that no medical insurance is provided by The Club.

I further understand that photographs and video may be taken during the Activities and that such media may be used by Cherry Creek High School, Colorado High School Water Polo Association, or Creek Polo Inc. for promotional or publicity purposes, including but not limited to social media platforms, team websites, and printed materials.

FOR PARTICIPANTS UNDER 18 YEARS OF AGE

As the parent or legal guardian of the minor participant named below, I hereby consent to his/her participation in the Activities. I have read and fully understand the above Agreement, Waiver, and Release, and I execute it on behalf of my child.

I certify that my child is physically able to participate in the Activities and that I have provided to the Club a medical waiver signed by my child's physician. I agree to indemnify and hold harmless the persons and entities listed above from any loss, liability, damage, cost, or expense that may be incurred as a result of the injury, death, or property damage that my child may sustain while participating in the Activities.

I attest that I have fully and truthfully answered all questions on the attached questionnaire to the extent of my ability and am not aware of any accidental or purposeful omissions.

ACKNOWLEDGMENT

I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT. I FULLY UNDERSTAND ITS TERMS AND UNDERSTAND THAT I AM GIVING UP SUBSTANTIAL RIGHTS BY SIGNING IT. I SIGN FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.

Print your Full Name as Signature *

Date Signed *

Email Address for Receipt CopySend Me a Copy of this Form

CREEK WATER POLO