Oklahoma City, OK June 22-23, 2011—Santa Fe Life Center
VBClinics.Com Volleyball Camp Authorization Form
Name _________________________________________________________________
Address_________________________________________________________________
City_______________________________ State____________ Zip_________________
Telephone Number________________________________________________________
E-mail_______________________________________________ (Please write clearly!)
Adult Shirt Size: (circle one) X-Large Large Medium Small
AGREEMENT OF RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK AND INDEMNITY
In consideration of and as inducement to my enrolling in the vbclinics.com Clinic at Santa Fe Life Center, I represent & agree as follows:
(1) I am aware that participation in the physical activity of volleyball may result in accident or injury, and I assume the risk connected with
participation in this volleyball clinic.
(2) I release and discharge Pat Powers and all vbclinics.com and Santa Fe Life Center,, staff of any and all claims of injury or damage that
may be sustained by me, my own actions, or inactions or the negligence of “Releasees” named below and from the following: use of premises,
any equipment, and its surroundings.
(3) I hearby release, discharge, and covenant not to sue Pat Powers, vbclinics.com, and/or Santa Fe Life Center,, their agents, coaches,
employees and/or staff and if applicable, owners of the premises, (each to be considered “Releasees” herein) from all liability, claims,
demands, losses, or damages on my account caused or alleged to be caused in whole or in party the negligence of the “Releasees” or
otherwise; and I further agree that if, despite this release and waiver of liability, assumption or risk, and indemnity agreement, I, or anyone on
my behalf, makes a claim against any of the “Releasees”, I will indemnify, save, and hold harmless, each of “Releasees” from any litigation
expenses, attorney fees, loss, liability, damage, or cost which may incur as the result of such claim.
(4) I have been examined by a licensed physician within the past 6 months and have been found by that physician to be in good physical
health and fully able to perform the volleyball skills which I am to learn at the clinic with you.
(5) I will faithfully follow all instructions given to me by you and your instructors and coaches and understand that any deviation by me from
such instruction shall be at my own risk.
(6) I will not hold you, your instructors and coaches, your partners, or employees responsible for any injuries suffered by me caused in whole
or in part by my failure to faithfully follow instructions of you or your instructors and coaches or by and physical impairment of mine not fully
disclosed to you in writing.
(7) In the event that I am pregnant, I will not attend a clinic until I have discussed the risks with my obstetrician, I will follow my doctor’s
recommendations and will not hold vbclinics.com and/or Santa Fe Life Center, responsible for any injuries to myself or my fetus caused in
whole or in part by my failure to follow my physician’s recommendation.
(8) If I am under 18 years of age, I have disclosed that information to vbclinics.com and my parent, and/or guardian has signed and dated this
waiver of liability at the bottom of this page.
_____________________________________________________________________________ Date: __________________
Signature/Parent or Guardian must sign for persons under 18 on behalf of themselves and their minor child
To secure a spot in the clinic, mail this form along with a check for $140 made out to Pat Powers to the following
address:
Pat Powers
Vbclinics.com
153 Phoebe St
Leucadia, CA 92024
Check #: ______________________ Amount: $