Womens Soccer ID Clinic January 13, 2012 9 a.m. - 3 p.m. Waiver: I understand that Duquesne University Women's Soccer staff and team members will NOT be held responsible for injuries or loss of property while the above player is attending and participating in the Duquesne University winter ID clinic. I do hereby release the State of Pennsylvania, Duquesne University, its officers, agents, and employees from all liability, including claimsand suits in law or equity for any injury, fatal or otherwise. The signature below absolves Duquesne University Women's Soccer staff of all responsibility for loss of personal property. Furthermore, I realize the risk involved to the player participating in sports. I will pay, or cover through my insurance, any medical or hospital expenses, doctor bills, or other expenses that could be incurred as a result of treatment given above named player for illness or injury while attending or subsequent to attending Duquesne University Women's winter ID clinic. I hereby authorize Duquesne University Women's Soccer staff to act for me according to their best judgment in any emergency requiring medical attention, and I state that the above applicant has been checked and is of sound physical condition to participate in the sport of soccer. I further understand Duquesne University Women's Soccer retains the right to use, for publicity and advertising purposes, photographs of players taken at the said ID clinic. I have read and understand the above.* * You must check that you accept the waiver to participate. Registration Information: Camper's First Name: Camper's Last Name: Address City State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming -- Other / Outside US Zip Code Phone Number: Email Address: Position: Age: Graduation Year: High School: Club Team: Parent/Guardian Information Family Physician: Phone: Parent/Guardian: Phone: Emergency Contact: Phone: After completing this online registration form, please send in a $90 check to: Duquesne Women's Soccer 600 Forbes Avenue Pittsburgh, PA 15282 Attention: Brian Shrum **Make checks payable to: Alvine Soccer Academy
