This authorization for Emergency Medical Treatment must be completed before participation in activities. Treatment for injury will be based on information provided herein. I, the understand participant or parent/guardian of the above listed minor, acknowledge and fully understand that each participant will be engaging in activities that involve risk of serious injury, including permanent disability or death, and severe social and economic losses which might result not only from their own actions, inactions, or negligence, but the action, inaction, or negligence of others, the rules of play, or the condition of the premises or of any equipment used and further, that there may be other unknown risks not reasonably foreseeable at this time, assume all the foregoing risk and accept personal responsibility for the damages following such injury, permanent disability, or death, hereby release, discharge, covenants to indemnify and not sue the Crawford County Futsal Club, its directors, officers, employees, coaches, managers, agents, sponsors, and associated personnel, as well as the owners of the premises used to conduct the event, the CUSD #2 Robinson School District, all of which are hereinafter referred to as ‘releasees’, from any and all liability to each of the undersigned, his/her heirs or next of kin for any and all against any claim by or on behalf of the applicant as a result of the applicant’s participation in the programs and/or being transported to or from the same, which participation, after careful consideration, I hereby authorize and which transportation I hereby authorize. The applicant/participant has received a physical exam by a physician and has been found physically capable of participating in the Program. I hereby give my consent to have an athletic trainer, coach, and/or medical doctor, dentist, or associated personnel to provide the applicant/participant with medical assistance and/or treatment and agree to be financially responsible for the cost of such assistance and/or treatment. I also agree to save and hold harmless and indemnify each and all parties herein referred to above as releasees from all liability, loss, cost, claim, or damage whatsoever, including death or damage to property, which may be imposed upon said releasees because of any defect in or lack of such capacity to so act or caused or alleged to be caused in whole or in part by the negligence of the releasees. I have read the above waiver/release and understand that I/we have given up substantial rights by signing this release and sign below voluntarily.

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PO Box 916, Robinson, Illinois. 62454