Participant Name:  Date of Birth:  Age: 

Sex:  M  F  Current Grade in School  Special Request (Coach):   

Parent Name:  Phone Number: Cell () 

Address: City:  State:  Zip: 

Email Address:

   I am Interested in Coaching - Name:  Email: 

  T-Shirt Size: (check one) Youth Sizes:  S (6/8) M (10/12)  L (14/16) Adult Sizes: S M L XL

  Check here if you DO NOT give permission for your minor child/ward(s) picture(s) to be on the City of Hickman Facebook, Website and/or Newsletter

REGISTRATION DEADLINE: July 20th, 2020

Late Fee of $15.00 Will Apply to Registrations Received After July 20th

NO REGISTRATIONS WILL BE ACCEPTED AFTER July 27th, 2020 at 5:00pm

Financial Assistance Program May Be Available

  I have read the Parent/Athlete Concussion Information Sheet

WAIVER AND RELEASE OF LIABILITY

Please read this form carefully and be aware that in participating you will be waiving and releasing all claims for injuries that you or your minor child/ward might sustain arising out of this participation.

As a participant or parent/guardian of a participant, I recognize and acknowledge that there are certain risks of physical injury and agree to assume the full risk of any injuries, including death, damages or loss which I or my minor child/ward may sustain as a result of participating in any and all activities connected with or associated with this program.

I agree to waive and relinquish all claims I or my minor child/ward may have against the City of Hickman and its officials, officers, agents, servants and employees as a result of participating. I do hereby fully release and discharge the City of Hickman and its officials, officers, agents, servants, employees and volunteers from any and all claims from injuries, including death, damage or loss which I or my minor child/ward may have or which may incur or may accrue to me or my minor child/ward on account of my participation.

I further agree to indemnify and hold harmless and defend the City of Hickman and its officials, officers, agents, servants, employees and volunteers from any and all claims resulting from injuries, including death, damages and losses sustained by me or my minor child/ward and or arising out of connected with, or in any way associated with the activities of my participation.

In accordance with Nebraska Statute 71-9105 (2011), parents and coaches must review the provided items that address the following:

1. The Signs and Symptoms of a Concussion;
2. The Risks Posed by Sustaining a Concussion; and,
3. The Actions an athlete should take in response to sustaining a concussion, including the notification of his or her coaches. (More information is available at www.cdc.gov/concussion/HeadsUp/youth.html)

By signing this form I acknowledge that I have read and fully understand the above warning of Risk and Waiver and Release of All Claims and have received information in accordance with Nebraska Statute 71-9105 regarding concussions.

Parent/Guardian Signature (Required)        Date 

CITY OF HICKMAN 

COVID-19:  Participants Agreement for Sports or Other Recreational Activities

(Please print clearly or type and fill in all blanks and sign below.)

Participant Name (Player, Coach, Official, or Other Participant):  

Address: 

State:  Zip:    

Telephone #: 

Age of Participant 

If Participant is 18 years of age or older, only Participant must sign.  If Participant is 17 years Old or Younger, Parent or Legal Guardian must sign. 

ACKNOWLEDGMENT AND ASSUMPTION OF RISK

The COVID-19 coronavirus has been declared a worldwide pandemic by the World Health Organization, is extremely contagious and is believed to spread mainly from person-to-person contact. By signing this, you ACKNOWLEDGE AND ASSUME THE RISK AND DANGERS OF ILLNESS, DISEASE, MEDICAL COMPLICATIONS, INJURY OR DEATH, caused by or related to COVID-19, by voluntarily entering the property and/or public facilities of the City of Hickman, Nebraska, a Nebraska municipality, (hereinafter referred to as “the Municipality”) and participating in or viewing adult and/or youth games, practices, or other group recreational activities, or by authorizing the participation of a minor in or the presence of a minor at such games, practices, or other group recreational activities.  No one guarantees that you or your child(ren) will not become infected with COVID-19. The person signing below voluntarily assumes this risk because s/he chooses or elects to do so. 

COVID-19 RELEASE AND INDEMNITY AGREEMENT AND COVENANT NOT TO SUE

In consideration of the above-listed player, coach, or official (“Participant”) being allowed to participate in adult and/or youth team sports or other group recreational activities on municipal property and/or public facilities, the Participant or the parent(s) or legal guardian (if Participant is a Minor), on his or her own behalf and on behalf of any Minor Participant, agree as follows:

1. I RELEASE, WAIVE, DISCHARGE AND COVENANT NOT TO SUE the Muncipality on whose property and/or public facilities Participant participates in any adult and/or youth games, practices, or other group recreational activities, together with each the Municipality’s Mayor and City Council, City Administrator, City Clerk, agents and employees, and all others who participate with Participant in such activities  (all of whom are collectively referred to herein as “Releasees”) from any and all liability

to the Participant (or Participant’s personal representatives, assigns, heirs, parents, legal guardians, siblings, children or dependents) on account of injury, illness, disease, quarantine or death from the COVID-19 coronavirus and any complication or related disease or condition, occurring as a result of entering the property  of the Municipality, participating in or viewing any such game, practice, or other group recreational activity, or other use of public facilities on the property of the Municipality, whether such injury, sickness, disease, condition, or death is caused by the negligence or other wrongful conduct of one or more of the Releasees or any other participants, spectators or other individuals present at the game, practice, or other group recreational activity, or whether liability for such injury, sickness, disease, condition, or death is assigned to one or more of the Releasees as a matter of strict liability or any other legal doctrine.

2. I AGREE TO INDEMNIFY AND SAVE AND HOLD HARMLESS THE RELEASEES and each of them from any liability, damage or loss (including, but not limited to, attorneys’ fees and other defense costs) one or more of them may suffer or incur arising out of or related to the Participant’s or any of the undersigned’s entry onto the property and/or public facilities of the Municipality in connection with any game, practice, or other group recreational activity, whether such claim is based on one or more of the Releasees' negligence, breach of contract or warranty, strict liability or other legal theory. The undersigned COVENANTS not to sue any Releasee related to injury, disease, loss, quarantine, or illness related to COVID-19.

3. THE PERSON SIGNING BELOW AGREE(S) to comply with all federal, state and local laws and regulations, all directed health measures and guidelines, and all security policies or procedures established by the Municipality relating to COVID-19 or other safety or hygiene precautions, understanding that the Municipality may elect to deny entrance to the property (including any facilities present thereon) and the Participant may not be allowed to participate or continue to participate in the game, practice, or other group recreational activity at the election of the Municipality at any time.  The undersigned agree(s) that in the event any portion of this document is held to be invalid, the balance shall, notwithstanding, continue in full legal force and effect to the greatest extent possible under applicable law.  The parents or guardian of the Participant agree that by signing below they are in addition to binding themselves and binding any minor Participant on whose behalf they have signed, to the maximum extent permitted by applicable law to this Agreement in full. 

I AM THE AGE OF MAJORITY, AM COMPETENT AND HAVE FULL AUTHORITY TO SIGN THIS, HAVE READ THE ABOVE AND UNDERSTAND ITS TERMS. I SIGN KNOWING ITS EFFECTS.