Name:__________________________________________ Grade:_____ Age:______

Name of Team or School:_______________________________________________

Address:______________________________________________________________

City:________________________________ State:________ Zip:_____________

Emergency Contact Name:_______________________________________________

Phone:(_______)_________________ Alt Phone:(_______)__________________

List any medical conditions that a coach/teacher should be aware of:

______________________________________________________________________



Participation Agreement and Release

Both parent(s) and player must read and sign this document. This Participation Agreement and Release must be signed before the player may participate in any DiscNW sponsored event. (name)_____________________________________ would like to participate in (name of event)_____________________________________, an activity of the Northwest Ultimate Association (a.k.a DiscNW). I (we) recognize that Ultimate is a hazardous and dangerous activity with inherent risks. I (we) recognize that such risks can lead to serious injury or death. I (we) have voluntarily made a choice to participate in this activity and expressly assume and accept the risks inherent in the activity. I (we) accept my (our) responsibility to be informed, to behave prudently, to conduct myself (ourselves) in a safe manner, and to read and abide by all reasonable and available sources of information about the activity. I (we) agree to release, hold harmless and indemnify the Northwest Ultimate Association and its employees, trustees, agents contractors, officers, volunteers, and other representatives from all claims for any injury or damage resulting from any cause, including negligence, which may arise out of participation in or travel to and from this activity. This release is binding as to any other persons, including family members, heirs, and executors. If I am signing on behalf of a minor, I recognize that I may not release any claim the minor may have. However, I accept full responsibility for all medical expenses and claims incurred as a result of the minor's participation in or travels to and from Ultimate activities. I also agree to release, hold harmless, and indemnify the Northwest Ultimate Association and its employees, trustees, agents contractors, officers, volunteers, and other representatives for any claims brought by the minor.

I (we), the undersigned, have carefully read and understand the "Participation Agreement and Release" and agree it is binding upon me (us).

Player __________________________________________ Date________________

Parent __________________________________________ Date________________