VIEWS: 56 PAGES: 3 POSTED ON: 7/19/2011
Lincoln High School Water Polo Club 2011 Athlete Info (please complete and return to Anita Stark, 4625 SW 53rd Avenue Portland, OR 97221 or scan and e-mail by August 15th) Athlete’s Name: _______________________ Year in School: __________ Address: ______________________________________________________ _____________________________________________________________ Parent Name: __________________________________________________ Home Phone: _________________________________________________ Parent Cell Phone: ______________________________________________ Athlete’s Cell Phone: ___________________________________________ Parent e-mail: _________________________________________________ Athlete’s e-mail: _______________________________________________ Emergency Contact Name: _______________________________________ Emergency Contact Phone: _______________________________________ Insurance Policy Name and Number: _______________________________ Any Medical Conditions: Lincoln High School Water Polo Club 2010 Waiver (please complete and return to Anita Stark, 4625 SW 53rd Avenue Portland, OR 97221 or scan and e-mail by August 15th) This waiver is for a Chartered Club Team that is registered with USA Water Polo and is affiliated with, but not sponsored by Lincoln High School/Portland School District. As a parent(s) or legal guardian(s) of ______________________________ or as a student member of the Lincoln High School Water Polo Team, I/we, undersigned, hereby release and agree to defend and hold harmless School District No. 1, Multnomah County, Oregon (district), its officers, agents, employees and their assigns and the team coaches and volunteer parents from any claims from any person, entity or estate, in any forum that may arise against them by reason of property loss or injury and/or death resulting from any cause including but not limited to the student or other students having failed to properly carry out instructions from the club leadership. Dated this __________ of ________________________. 2010. Signature of Parent or Legal Guardian _____________________________ Printed Name of Legal Guardian __________________________________ Signature of Athlete____________________________________________ Printed Name of Athlete_________________________________________
"2011 Polo Registration"