If the player is under 18 years of age or is unable to fill out this form, a parent or legal guardian must sign it.

Participant's Name (First and Last)

Date of Birth (MM/DD/YYYY)

Address

City

State

Zip Code

Email

Phone

Parent/Guardian's Name (First and Last)

Relationship

Email

Phone

Emergency Contact (Other than parent/guardian)

Relationship

Email

Phone

Disability

Allergies (Food and Environmental)

List any medical precautions

I. LIABILITY RELEASE FORM - 2022-23

In participating in and/or receiving program services under the auspices of the Philadelphia PowerPlay, it is understood that there are normal risks involved. Due to the fact that eligibility to participate in these services is based on exhibiting a developmental disability, it is understood that these normal risks become somewhat greater.

Any equipment or auxiliary aids or assistance of any nature whatsoever that I or my advisors believe necessary for my full participation in the activities of the Philadelphia PowerPlay will be provided by me, with no request for assistance from the Philadelphia PowerPlay or any host team of tournaments or special events. It is understood that all players MUST personally provide all accommodations and equipment (including but not limited to aides, specially adapted sticks, transportation, etc.) necessary to participate in the games and/or social activities at the regular bi-monthly games, as well as any tournaments or exhibitions which the player elects to participate in with the team. It is understood and agreed that the Philadelphia PowerPlay, or any host team, has no financial responsibility to provide for any services or equipment.

In consideration of your acceptance of my application for the Philadelphia PowerPlay and granting permission for my participation in this activity, I hereby intend to be legally bound, for myself, my heirs, executors and administrators, waive and release any and all claims of any kind for damages of any nature which I or my beneficiaries may now or hereafter have against Philadelphia PowerPlay and any sponsors, coordinating groups, facilities and individuals associated with the activity, their representatives, successors and assigns, and will hold them harmless from any injuries or damages which I may suffer in this activity.

I understand that the appropriately designated Philadelphia PowerPlay staff or representative will follow their normal procedures in their best professional judgment in providing services and responding to situations of an emergency nature.

I also specifically agree that any claim by me that Philadelphia PowerPlay or any of its officers or employees has engaged in unlawful discrimination (such as is addressed by Title VII, the Civil Rights Act, the Age Discrimination Act, the Americans with Disabilities Act, the Pennsylvania Human Relations Act) which results in litigation involving such claims shall be resolved by binding arbitration, pursuant to the rules of the American Arbitration Association, with the location of said arbitration to be in Media, Delaware County, Pennsylvania. Each side shall pay for and bear one half of the costs of the arbitration and of the arbitrator, as well as its own costs and counsel fees; however, regardless of whether the results of said arbitration favor Philadelphia PowerPlay or me and regardless of who is the substantially prevailing party in said arbitration, I acknowledge that there is a benefit to arbitration in that it is faster, less expensive, less formal and has the potential for expending less of my counsel fees, than litigation.

I certify that I have read/or have had read to me and fully understand the above statement and that my participation in and/or receipt of these Philadelphia PowerPlay services is voluntary and without reservation.

If the player is under 18 years of age or is unable to fill out this form, a parent or legal guardian must sign it.

Participant's Signature

Today's Date (MM/DD/YYYY)

Parent/Guardian's Signature

Today's Date (MM/DD/YYYY)

Your electronic signature above on this application will constitute the legal equivalent of your signature.

II. PERMISSION TO PHOTOGRAPH

I DO grant permission to the Philadelphia PowerPlay to take and use photographs and/or videos of me while participating in Philadelphia PowerPlay sponsored events for use of publicity, future public relations brochures, the Internet and for fund-raising purposes.I DO NOT grant permission to the Philadelphia PowerPlay to take and use photographs and/or videos of me while participating in Philadelphia PowerPlay sponsored events for use of publicity, future public relations brochures, the Internet and for fund-raising purposes.

If the player is under 18 years of age or is unable to fill out this form, a parent or legal guardian must sign it.

Participant's Signature

Today's Date (MM/DD/YYYY)

Parent/Guardian's Signature

Today's Date (MM/DD/YYYY)

Your electronic signature above on this application will constitute the legal equivalent of your signature.

III. CONSENT FOR TREATMENT

In case of an accident or illness, I hereby authorize a representative from Philadelphia PowerPlay to use his/her judgement in obtaining immediate medical care. (Parents/Guardians/Spouse will be notified in case of serious illness or injury as quickly as they can be reached. This signed document will make immediate treatment possible.)

If the player is under 18 years of age or is unable to fill out this form, a parent or legal guardian must sign it.

Participant's Signature

Today's Date (MM/DD/YYYY)

Parent/Guardian's Signature

Today's Date (MM/DD/YYYY)

Your electronic signature above on this application will constitute the legal equivalent of your signature.

IV. PERMISSION TO DISTRIBUTE INFORMATION (FOR TEAM CONTACT LIST)

I DO grant permission to the Philadelphia PowerPlay to distribute my contact information to the rest of the team for easy communication between players and parents, and for fund-raising purposes.I DO NOT grant permission to the Philadelphia PowerPlay to distribute my contact information to the rest of the team for easy communication between players and parents, and for fund-raising purposes.

If the player is under 18 years of age or is unable to fill out this form, a parent or legal guardian must sign it.

Participant's Signature

Today's Date (MM/DD/YYYY)

Parent/Guardian's Signature

Today's Date (MM/DD/YYYY)

Your electronic signature above on this application will constitute the legal equivalent of your signature.