Print out a copy of this insurance liability release form, sign it, and mail it along with your check. Players may not participate without turning in a signed release form.
Mail your check and release form to: Junior Prep Stars, 6 Abingdon Way, Durham, NC 27713
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Player's Name League/Camp Grade Level
Insurance Liability Release (Acknowledgement and Assumption of Risk)
All players must have insurance before playing

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Player's Insurance Company
Insurance Policy #

List any special needs (medications, previous injuries, etc. which will require our coaching staff's knowledge:

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I understand that participation in this activity involves the risk of injury. These risks include but are not limited to collision with other participants, being hit by the ball, falling to the floor or into a wall, scratches, bruises, etc. I further understand that before participating in this program I should consult a physician for advice.

By signing this form I acknowledge all risks of injury and death and affirm that I am willing to assume responsibility should injury or death result from them. I also agree to follow all rules and procedures of the program and to follow the reasonable instructions of the teachers.

In return for the opportunity to participate in this program I agree for myself, and for my heirs, assigns, executors and administrators, to waive any legal right I may have to seek payment of any kind from Junior Prep Stars: its employees or its agents for bodily injury or death resulting from this program, and to release those parties from any liability for damages resulting from injury or death. I understand that no additional insurance coverage is provided by Junior Prep Stars.


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Parent/Guardian Signature
Date