Team Name ____________________________________________________

Last Name ___________________________________________  First Name ______________________________________________________

Address _____________________________________________________________________________________________________________

City, State, Zip ________________________________________________________________________________________________________

E-mail ________________________________________________________

Emergency Contact ____________________________ Relation ________________________ Phone Number ____________________________      

Student’s Birth Date _____________________________________ Special Needs? _________________________________________________

Insurance Carrier _______________________________________ Policy Number __________________________________________________

RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT ("AGREEMENT")

In consideration of participating in the ____________________________________ I represent that I understand the nature of this Activity and   
that I am qualified, in good health, and in proper physical condition to participate in such Activity.  I acknowledge that if I believe event conditions
are unsafe, I will immediately discontinue participation in the Activity. 

I fully understand that this Activity involve risks of serious bodily injury, including permanent disability, paralysis and death, which may be caused
my own actions, or inactions, those of others participating in the event, the conditions in which the event takes place, or the negligence of the
"releasees" named below; and that there may be other risks either not know to me or not readily foreseeable at this time; and I fully accept and
assume all such risks and all responsibility for losses, costs, and damages I incur as a result of participation in the Activity.

I hereby release, discharge, and covenant not to sue ______________________________________, its respective administrators, directors, 
agents, officers, volunteers, and employees, other participants, any sponsors, advertisers, and if applicable, owners and lessors of premises
on which the Activity takes place.  (each considered one of the "RELEASEES" herin) from all liability, claims, demands, losses, or damages on my
account, caused or alleged to be caused in whole or in part by the negligence of the "releasees" or otherwise, including negligent rescue
operations; and I further agree that if, despite this release, waiver of liability and assumption of risk I, or anyone on my behalf, makes a claim
against any of the Releasees, I will indemnify, save, and hold harmless each of the releasees from any loss, liability, damage, or cost which any 
may incur as the result of such claim.

I have read this RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT, understand that I have given up
substantial rights by signing it and have signed it freely and without any inducement or assurance of any nature and intend it be a complete and
unconditional release of all liability to the greatest extend allowed by law and agree that if any portion of this agreement is held to be invalid the
balance, notwithstanding, shall continue in full force and effect.

Printed name of Participant: ____________________________________________                          Date: ________________________________

Signature of Participant: _______________________________________________

PARENTAL CONSENT

AND I, the minor's parent and/or legal guardian, understand the nature of the above referenced activities and the minor's experience and
capabilities and believe the minor to be qualified to participate in such activity.  I hereby release, discharge, covenant not to to sue and AGREE
TO INDEMNIFY AND SAVE AND HOLD HARMLESS each of the Releasees from all liability, claims, demands, losses, or damages on the minor's
account caused or alleged to have been caused in whole or in part by the negligence of the Releasees or otherwise, including negligent rescue
operations, and further agree that if, despite this release, I, the minor, or anyone on the minor's behalf makes a claim against any of the above
Releasees, I WILL INDEMNIFY, SAVE AND HOLD HARMLESS each of the Releasees from any litigation expenses, attorney fees, loss liability,
damage, or cost any Releasee may incur as the result of any such claim.

Printed name of Parent/Guardian: ________________________________________                      Date: _________________________________

Signature of Parent/Guardian: ___________________________________________

Complete and send to:   SuperCDA   |  P.O. Box 957491   |   Hoffman Estates, Illinois  60195-7491