Head of Household Information:

Last Name:_____________________First Name:________________Middle Initial: ______

Address:________________________________City:_____________Zip:________________

Daytime Phone: ( _____)__________________Evening Phone:(____)___________________

Email Address ________________________________________________________________

Emergency Number: ____________________ Contact Name:_________________________

Name of each minor child participating:

  1. ___________________________________
  2. ___________________________________
  3. ___________________________________
  4. ___________________________________

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Release of Liability Waiver

Please read this form carefully and be aware that in signing and participating in this program/activity, you will be expressly

assuming the risk and legal liability and waiving and releasing all claims for injuries, damages or loss which you or your minor

child/ward might sustain as a result of participating in any and all activities with and associated with this program/activity. 

 

I recognize and acknowledge that there are certain risks of physical injury to participants in this program/activity and I

voluntarily agree to assume the full risk of any and all injuries, damages or loss regardless of severity, that my minor child/

ward or I my sustain as a result of said participation.  I further agree to waive and relinquish all claims I or my minor child/

ward may have (or accrue to me or my minor child/ward) as a result of participating in this program/activity against Eich’s

 Sports, its owners, including its officials, agents, volunteers, contractors and employees (hereinafter collectively referred

to as “Eich’s Sports”)

 

I do hereby fully release and discharge Eich’s Sports from any and all claims for injuries, damages or loss sustained by anyone

 arising out of, connected with, or in any way associated with this program/activity.

 

By signing this waiver, I understand that my child/ward or I may be photographed or videotaped at any Eich’s Sports program,

event, or facility.  I give my permission for photographs and videotapes of my child/ward or me to be used to promote Eich’s

Sports through press releases, brochures, the web site, and other promotional materials.  Such photographs and videotapes will

 remain the property of Eich’s Sports.  Please tell the instructor or photographer if you do not want to be photographed.

 

Participant’s Signature Required:

 (A parent/guardian must sign if participant is under age 18)

 

_______________________________________________________________Date:_________

Signature                                                             Print Name

                                     

                                       Please return this form to Eich’s Sports

                         24316 W. 143rd St. Plainfield, IL 60544 – (815) 436-9044 or Fax to (815) 436-3686