As the parent or legal guardian of the child named below, I hereby give my full consent and approval for
my child to participate in all activities below. I understand that there are
certain risks of injury inherent in the practice and play or any activity, as well as in traveling and other
related activities incidental to my child’s participation, and I am willing to assume these risks on behalf
of my child. I hereby certify that my child is fully capable of participating in the designated sport and
that my child is healthy and has no physical or mental disabilities or infirmities that would restrict full
participation in these activities, except as listed below

In addition to giving my full consent for my child’s participation, I do hereby waive, release and hold
harmless the organization named below, its officers, coaches, sponsors, supervisors and representatives
for any injury that may be suffered by my child in the normal course of participation in the designated
sport and the activities incidental thereto, whether the result of negligence or any other cause.

I also grant Uniondale Empowerment Recource permission to take photographs and/or video of my child while participating in club activities. The photographs and videos will be used for information through any or all of the
following formats: Website, flyers, brochures, newsletters, presentations, Facebook and other marketing activities.