LA CANADA WATER POLO – PLAYER REGISTRATION FORM -

SPRING: April 1 thru June 20 (end of school)

COST: $225.00 Spring only. Please make checks out to LA CANADA WATER POLO.

PLEASE COMPLETE THE FOLLOWING AND RETURN TO ONE OF THE COACHES ASAP…

PLAYER:____________________________________ Date of Birth __________

PLAYER: EMAIL: _________________________________

Parent: EMAIL: _________________________________

U.S. Water Polo Registration Number:_____________ Expires: ____________

School: _____________________ Grade: ________(2006-07Year)

Parent Name(s): _________________________________________________

Address: ___________________________________________________

City/State/ZIP: ___________________________________________________

Home Phone: __________________________________________________

Parent Work Phones: _______________________________________________

Cell Phones: ______________________________________________________

Medical Restrictions or Allergies: ______________________________________

Game and practice notices go to these e-mail addresses. We encourage you to provide multiple addresses, including those of the parents, as player mailboxes may fill up or not be checked. Please also monitor WWW.LCWATERPOLO.ORG.

By signing below the parent or guardian of the Player named above, hereby: 1) Acknowledges that games, tournaments and other related events ("Events") may or may not be sanctioned by the La Canada School District, US Water Polo, or other sanctioning agencies. 2) Grants permission for the Player to be transported to Events by any coach, team parent, or other volunteer driver, or by bus provided by the La Canada School District, and agrees that any such drivers shall be indemnified and held harmless for any loss, cost, damage or expense relating to such transportation, except to the extent arising from gross negligence or willful misconduct. 3) Grants permission to any coach or other adult supervising the team or any Event (which may include any team parent designated by the coaching staff) to authorize medical treatment for the Player in the case of any emergency, and agree to pay for all costs associated with the procurement of any medical care or associated transportation provided to the Player. 4) Certifies that there is no known physical or medical condition, which would limit the ability of the Player to safely engage in the sport of water polo, and accepts all related risks. 5) Acknowledges that water polo and the training activities associated with water polo involve the risk of serious injury, disability or death, and agrees to release, indemnify, and hold harmless all coaches, agents, team parents, and other representatives for any injury or property damage sustained by the Player as a result of their participation in the activities contemplated hereby, except to the extent arising out of the gross negligence or willful misconduct of the person so released and indemnified.

Parent/Guardian Signature: ___________________________ Date: ________

Parent/Guardian Signature: ___________________________ Date: ________