PRINT NAME OF PERSON REQUESTING USE: __________________________________________________________________

ADDRESS OF PERSON REQUESTING USE: _____________________________________________________________________

SIGNATURE OF PERSON REQUESTING USE: ____________________________________________

DATE:___________________________________

BEFORE ANY USE OF THE POTOMAC STORM GYM, ALL PERSONS ENTERING THE GYM MUST READ, SIGN, AND DATE THE RELEASE BELOW & SUBMIT IT TO POTOMAC STORM VBC 

RELEASE OF LIABILITY FOR USE OF FACILITY AND/OR EQUIPMENT

READ BEFORE SIGNING

IN CONSIDERATION OF my child/ward/myself being allowed to participate in any way, in ANY event and/or activity held on any leased or owned premises of Panhandle Youth Volleyball Association, Incorporated dba Potomac Storm Volleyball Club; its directors, officers, officials, agents, employees, volunteers, other participants, sponsoring agencies, sponsors, advertisers, and owners and lessors of premises, (hereinafter individually and collectively known as the CLUB), whether such activity is at the Club's 64 Dupont Road, Martinsburg WV facility or at any other facility utilized by the Club, the undersigned acknowledges, understands, and agrees that:

The risks of injury and illness (including communicable diseases such as MRSA, influenza, and COVID-19) to my child/myself/and others from the activities involved in these programs are significant, including the potential for permanent disability and death, and while particular rules, equipment, and personal discipline may reduce these risks, the risks of serious injury and illness do exist; and,

1. FOR MYSELF, MY SPOUSE, AND CHILD, I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE CLUB, or others, and assume full responsibility for my child’s use of the Club's facility(s) and equipment; and,

2. I willingly agree to comply with the Club’s stated and customary terms and conditions for participation. If I observe any concern, I will remove my child from the participation and the Club's facility immediately; and,

3. I myself, my spouse, my child, and on behalf of my/our heirs, assigns, personal representatives and next of kin, HEREBY RELEASE AND HOLD HARMLESS the Club, WITH RESPECT TO ANY AND ALL INJURY, ILLNESS, DISABILITY, DEATH, or loss or damage to person or property, incidental to my child’s involvement or participation in these programs and/or use of the Club's facility(s) and/or equipment, WHETHER ARISING FROM THE NEGLIGENCE OF THE CLUB OR OTHERWISE, to the fullest extent permitted by law.

4. I, for myself, my spouse, my child, and on behalf of my/our heirs, assigns, personal representatives and next of kin, HEREBY INDEMNIFY AND HOLD HARMLESS the CLUB from any and all liabilities incidental to our involvement or participation in these programs and/or use of the Club's facility(s) and/or equipment, EVEN IF ARISING FROM CLUB'S NEGLIGENCE, to the fullest extent permitted by law.

5. I, the parent/guardian, assert that I have explained to my child/ward: the risks of the activity, his/her responsibilities for adhering to the rules and regulations, and that my child/ward understands this agreement.

I, FOR MYSELF, MY SPOUSE, AND CHILD/WARD, HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND IT'S TERMS, UNDERSTAND THAT WE HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.

Print Name of Participant: _______________________________________

Print Name of Parent/Guardian (If Participant is UNDER 18 years of age): _______________________________

Signature of Parent/Guardian/Participant (If Participant is 18 years of age): __________________________________

Date Signed:___________________________________ 

Name of Child/Ward: ___________________________________

Signature of Child/Ward: __________________________________

Date Signed:___________________________________