B R O O K L Y N S B A S E B A L L C L U B S
P. O. B O X 1 4 0 0 7 8
B R O O K L Y N , N E W Y O R K 1 1 2 1 4

P A R E N T__ W A I V E R__ &__ C O N S E N T__ F O R M

2 0 1 5__S E A S O N


I, THE UNDERSIGNED PARENT, DO HEREBY PERMIT AND AUTHORIZE MY SON

_____________________________________ , BORN _________ , AND RESIDING AT
.........................full name .............................................mo day yr

___________________________ _________ , NEW YORK ______, TO PARTICIPATE
............................address .................boro .............................zip

IN THE BASEBALL PRIVATE PRACTICE PROGRAM CONDUCTED BY THE " BROOKLYNS" BASEBALL CLUB.

I RELEASE THE AFORESAID ORGANIZATION, ITS BASEBALL PROGRAM COACHES AND

DIRECTOR MR. ANTHONY DALILEO AND THOSES COACHES ASSISTING HIM FROM ANY

LIABILITY OR CLAIM ARISING FROM MY SONS PARTICIPATION IN THIS PROGRAM.

I TAKE SOLE RESPONSIBILITY FOR MY SONS BEHAVIOR.

TO THE BEST OF MY KNOWLEDGE OF MY SONS PAST MEDICAL HISTORY,
................__ . __
MY SON |__| |__| PHYSICALLY ABLE TO PARTICIPATE IN ATHLETICS AND IN
.............. (IS) (IS NOT)
BASEBALL. I AUTHORIZE MY SON TO PARTICIPATE IN ANY QUANTITY OF PHYSICAL

EXERCISES OR ACTIVITY THAT HE INDIVIDUALLY OR AS A MEMBER OF THE PRACTICING GROUP IS REQUESTED TO PERFORM.
................__ ..__
MY SON |__| |__| COVERED BY A MEDICAL INSURANCE POLICY.
.............. (IS) (IS NOT)

I SHALL ASSUME FINANCIAL RESPONSIBLE FOR THE MEDICAL COSTS INCURRED BY MY SON DUE TO
AN INJURY THAT MAY OCCUR TO MY SON DURING HIS PARTICIPATION IN THIS
BASEBALL PROGRAM CONSISTING OF PRACTICE SESSIONS. I REALIZE THAT MY SON
WILL NOT BE COVERED BY A TEAM MEDICAL INSURANCE POLICY DURING HIS
PARTICIPATION. I UNDERSTAND THAT THERE ARE RISKS OF INJURY DURING
PARTICIPATION IN A PRACTICE BASEBALL PROGRAM AND I ASSUME THOSE RISKS.

I AM MY SONS |_| PARENT |_| LEGAL GUARDIAN

___________
...........................................________________________________
...... date .....................................................................parents signature