RELEASE AND WAIVER OF LIABILITY AGREEMENT
Clinic Location:
Participant Name*
Clothing Size
Shoe Size
Participant’s Address *
The participant understands that the Event, and participating in the Event, carries with it inherent dangers
and/or risks of physical injury, including serious injury such as permanent disability, paralysis and even
death. We are voluntarily participating in the Event with knowledge of the potential dangers and/or risks
involved, and agree to assume any and all dangers and/or risks of bodily injury or death, whether those
dangers and/or risks are known or unknown.
In consideration of being allowed to participate in the Event we, the Participants, individually and jointly
hereby agree to forever release and hold harmless the Football Federation Australia Limited, Sydney
Football Club Pty Limited , its directors and employees in the event of injury to any Participant. We also
acknowledge that the Football Federation Australia Limited and Sydney Football Club Pty Ltd does not
have in place any personal accident insurance policy that would provide us with any compensation or
benefits in the event of any Participant being injured.
We, the Participants, have carefully read and fully understand this waiver and release and agree to
release the Football Federation Australia Limited and Sydney Football Club Pty Limited from any
liability for any injury or other losses we incur, including Football Federation Australia Limited and
Sydney Football Club Pty Limited acts of negligence or omissions to the fullest extent permitted by
law. We also acknowledge and agree that we are signing this waiver of our own free will.
By agreeing to this release and waiver form we:
(a) expressly state that we have read this document and fully understand and accept its contents;
(b) warrant that all of the information contained in this application is true and correct; and
(c) acknowledge that the Football Federation Australia Limited and Sydney Football Club Pty Limited
has relied on the accuracy of this information in allowing me to participate in the Event.
Parent or Guardian: I verify that the dangers and/or risks of participating in the Event and the significance
of this release and waiver have been explained to the Participant and that the Participant understood them.
Please tick to confirm that you understand this release and waiver of liability agreement
RECOMMENDATION
It is recommended that all participants and visitors have private health insurance and ambulance cover as
any injury or incident requiring medical assistance will result in expenses.
Medical Information
Child Medical D.O.B*
First Medicare Number*
1. Has your child ever suffered from: (Tick where applicable)
Allergies
Heart or lung complaint
Diabetes
Epilepsy
Asthma
Extra Details:
2. Is your child taking any DRUG or MEDICATION or under any type of TREATMENT or have any
CONDITION which may prevent full involvement in the programme?
If yes please give details below. (e.g. Ventolin for Asthma. N.B. Asthmatics should bring a spare puffer)
Extra Details:
3. Does your child have any special dietary/food requirement? If so please give details (This does not
include foods that are disliked)
Extra Details:
Primary Contact Person - parent or guardian contact details
Name*
Email address*
Relationship*
Home Number
Mobile Number*
Work Number
Secondary Contact Person - parent or guardian contact details
Name*
Relationship*
Home Number
Mobile Number*
Work Number
Photographic & Film Image Approval
Sydney FC advises that photographic and film images of participants in the game of football may be used
for the purpose of promotion and marketing of the game.
Please read the following approval:
I agree to SYDNEY FC using my name and image in the promotion, website and marketing of Sydney FC's
community program that will be conducted.
PARTICIPANT APPROVAL:
Yes I agree to the above
No I do not wish to be included
PARENT / GUARDIAN APPROVAL:
This section must be co-approved by a parent or guardian if the participant is aged Under 18 years.
Please tick here to agree to the above
PAYMENT DETAILS
Credit Card Name:
Credit Card Number:
Expiry Date:
Please circle:
Visa/MasterCard/American Express*
*AmEx incurs a 3% surcharge on purchases