Kozak Sports Center
Activity Registration, Release and Waiver Form
	(Please Print clearly and legibly)
								Circle One
		Name of Participant:						Male	Female
		Address
		City				State:		Zip:
		Home Phone No.:
		Email:
		If Schedule changes occur, we will attempt to contact you via Pone and Email
			M	D	Y			Current School Year
		Participant Birth Date:				Age:		Grade:
		Fathers Name:				Work Phone:
		Mothers Name:				Work Phone:
		Emergency Contact:				Phone:
	Sport:				Start Date:		Day of Week:
	Type (Circle One):		League	Club	Training	Camp	Tournament
	Name of Team (if apply):					Team Representative:
	If Soccer (circle one):		Club	Travel	Recreation	Leisure
	Indicate preferred level of play:			High	Intermediate	Low
	ADULT and MINOR Participant Waiver/Release Agreement
In consideration of participating in any way in the athletics/sports programs and / or otherwise participating in or attending events or activities, at Kozak Sports Center, during the 12 month period between Jan.1 and Dec. 31coinciding with the date of receipt of this document the undersigned:
1	Agrees that he or she or the parent (s) or legal guardian (s) of the minor participant understand, and/or will instruct the minor participant, that prior to participating he or she shall inspect the facilities and equipment to be used, and if the participant believes anything is unsafe, he or she shall immediate inform his or her coach/supervisor, or personnel employed by Kozak Sports Center of such condition (s) and refuse to participate unless and until such condition (s) is cured or removed.
2	Acknowledges and fully understands that each participant will be engaging in activities that involve risk of serious injury, including permanent disability and death, and that sever social and economic loss may result in not only from his or her own actions, inaction or negligence but from the actions, inactions or negligence of others, as well as the rules of play, the condition of the premises or from any equipment used. Further that there may be other risks not known to the adult and or minor participant including risks that may not be reasonably foreseeable.
3	Assumes all of the foregoing risks and accepts personal responsibility for any injury, disability or death and any damages, whether social or economic.
4	Represents that I, or my child, and qualified, in good health and in proper physical condition to participate in activity (is) at Kozak Sports Center and hereby authorize any representative of Kozak Sports Center, or medical provider, to seek medical attention on my behalf, or on behalf of my child, to ensure my well being, or the well being of my child, without any legal liability whatsoever, inclusive of any responsibility for any negligent rescue operations.
5	Releases, waives, discharges and covenants not to sue Kozak Sports Center, it's affiliated clubs, administrators, members, directors, agents, coaches, referees, and other employees of Kozak Sports Center, other participants, sponsoring agencies, sponsors, advertisers, and if applicable, owners and lessors/lessees of the premises and all liability to each of the undersigned, his or her heirs and the next of kin, for any and all claims, demands, losses or damages on account of nay injury, including death or damage to property, caused or alleged to have been caused in whole or in part, by the releases or otherwise.
6	I hereby authorize Kozak Sports Center to utilize in any promotional materials any photograph take of me, or my child, while participating in any activity at Kozak Sports Center.
I/WE HAVE READ THE ABOVE AGREEMENT AND UNDERSTAND THAT I/WE GIVE UP CERTAIN RIGHTS BY VOLUNTARILY SIGHING IT AND I/WE NEVERTHELESS DO SO.
PRINT		Name of Parent, Guardian, or Adult Participant:
SIGN		Name of Parent, Guardian, or Adult Participant:
						Legal Signature
Date:
If Applicable, please record Your Payment Information			Make Checks Payable to:			Gene Kozak
			Check: #		Cash:			Amount:
6 Middleburry Blvd. Randolph NJ 07869
				Customer Signature:
							Please Sign