South Bay United Player Registration Form:

Optional fields are denoted by an asterisk (*). All other fields are required for registration.

Session

Player First Name

Player Last Name

Gender Male Female

USA Water Polo Membership #

Expiration Date

Player Birthday

Choose the appropriate program

Grade

School

Primary Phone Number

Street Address

City

Zip Code

Email Address

Additional Email Address *

Parent Name

Contact Phone Number

Parent Name *

Contact Phone Number *

In case of emergency parents will be notified first. If you would like, you may add an additional emergency contact below.

Emergency Contact Name *

Emergency Contact Phone Number *

Emergency Contact Name *

Emergency Contact Phone Number *

Physician’s Name

Physician’s Phone Number

Allergies

Medications (if none, write "NONE")

Please indicate your interest in serving on one or more of the following committees: *

Board of Directors

PR/Advertising

Team Parent

Sponsorship

EMERGENCY MEDICAL AUTHORIZATION: (Agent: Authorized Agent of South Bay United Water Polo Club)
I/We, parent(s)/person(s) having legal custody/guardianship of a minor, do hereby authorize medical, dental or surgical diagnosis or treatment, and hospital care which is deemed advisable by, and is to be rendered under the general or on the medical staff of any hospital, whether such diagnosis or treatment is rendered at the office of said physician, dentist, or at said hospital. It is understood that this authorization is given in allowance of any special diagnosis, treatment, or hospital care being required but is given to provide authority to the aforesaid Agent to give specific consent to any and all such diagnosis, treatment, or hospital care which a physician or dentist meeting the requirements of this authorization may in the exercise of his/her best judgment deem advisable.
This authorization is given pursuant to the provisions of Sections 6910 and 6550 of the Family Code of California.
This authorization shall remain effective until December 31, 2009 unless sooner revoked in writing delivered to said agent(s).

RELEASE AGREEMENT: We, the undersigned parent(s) or legal guardian(s) of the undersigned minor (South Bay United Water Polo Club Player) for ourselves and on behalf of the Player, our heirs, assigns and agents acknowledge that participation and/or receiving instruction in water polo necessarily involves travel, play in adverse weather conditions, physical contact and risk of severe and permanent physical injury. For myself, and on behalf of the Player, our heirs, assigns and agents, we willingly and voluntarily accept and assume all such risk. In consideration of accepting the registration and permitting the voluntary participation of the Player in the water polo program of the South Bay United Water Polo Club, for ourselves and on behalf of Player, our heirs, assigns and agents, we hereby release, discharge and agree to hold harmless South Bay United Water Polo Club, its employees, volunteers, officials, sponsors, officers, directors, owners and other representatives from any and all claims (including but not limited to personal injury, property damage and wrongful death claims), demands, costs, expenses and compensation arising out of or in any way related to any physical injury or other damages that may result from Player participating and/or receiving instruction in any water polo event sponsored and/or operated by South Bay United Water Polo Club, including any physical or other injury caused by the negligence of any person while performing his/her duties at any time. We understand and agree that this Release will have the effect of releasing, discharging, waiving and forever relingquishing any and all actions or causes of action that we may have or have had, whether past, present, or future, whether known or unknown, and whether anticipated or unanticipated by me, arising out of my participation and/or receipt of instruction in water polo. This release constitutes a complete release, discharge and waiver of any and all actions or causes of action against South Bay United Water Polo club. For ourselves and on behalf of the above Player, we further aknowledge that South Bay United Water Polo Club is primarily administered by volunteers rather than paid professionals. Four ourselves and on behalf of the above Player, he/she, we voluntarily agree to comply with the stated and customary terms and conditions for participation and, if he/she or we observe any unusual significant concern in his/her readiness for participation and/or in the program itself, we will remove him/her from participation and bring such concern to the attention of the nearest South Bay United Water Polo Club official immediately.

ACKNOWLEDGEMENT & CONSENT TO EMERGENCY MEDICAL AUTHORIZATION AND RELEASE AGREEMENT: By sumbitting this form, I/We consent to emergency medical treatment as stated above. I/We acknowledge that we have read this Release Agreement and that I/we understand the terms, and understand that I/we and the Player have given up substantial rights by my/our signing this Release Agreement and agreeing to these terms, and I/we sign this Release Agreement and agree to these terms freely and voluntarily and without inducement for ourselves and on behalf of the Player.