Dallas cup XXII

Dr Pepper Dallas Cup XXXVIII

Player Liability/Medical/Media Release and Indemnity Agreement

By my signature(s) below, I certify and confirm that I am the parent or legal guardian of ________________________________________, a player (“Player”) who desires to participate in the Dr Pepper Dallas Cup XXXVIII, April 9 – April 16, 2017, the international youth soccer tournament (“Dallas Cup”) of the Dallas Cup, Inc., a Texas non-profit corporation, at Dallas, Texas, USA. I also desire that Player be allowed to participate in soccer matches in Dallas Cup. As a parent or legal guardian, and individually, I acknowledge that Player’s participation in any soccer match, including the matches in Dallas Cup, involves a risk of injury to Player. As a parent or legal guardian for Player, and despite such risk, I expressly assume that risk of injury to Player, a minor child, and to induce Dallas Cup to permit Player to participate, I enter into this Agreement, and I agree and confirm the following: (1) Player is physically fit and able to participate in all respects in Dallas Cup; and (2) I hereby release, and agree to fully indemnify and hold the Dallas Cup, Inc., Dallas Cup, North Texas State Soccer Association, and their affiliates, and respective members, directors, officers, employees, volunteers, vendors, insurers, attorneys, and agents (“Indemnitees”) harmless from any and all claims, demands, actions, causes of action, losses, damages, or liability (including, without limitation, all expense of litigation, court costs, and attorneys’ fees) for any injury to or death of Player or to any other person whatsoever. Without limiting the scope of the foregoing, this Release and Indemnity Agreement specifically includes any and all claims in any way arising out of or related to Player’s participation in Dallas Cup, including, without limitation, any participation in a soccer match during Dallas Cup, and any claims for medical expenses, pain and suffering, physical disfigurement, mental anguish, emotional distress, loss of consortium, or for lost wages, or any injury to any property received or sustained by any person or property, EVEN IF SUCH CLAIM IS BASED ON A CLAIMED NEGLIGENT ACT OF ANY OF THE INDEMNITEES. Further, the undersigned agrees that the Dallas Cup, Inc. has no right of control or influence on the safety or security of the premises on which the soccer matches occur or any person or property entering onto such premises.

Player Medical Authorization

Further: (i) I understand and agree that the Indemnitees, collectively or individually, do not assume any financial responsibility for any medical services and/or treatment incurred by Player, or the undersigned for Player, or provided by any hospital, physician, or any other health care provider to Player.

(ii) I hereby certify that Player is covered for illness and/or injury (including without limitation illness and/or injury occurring in the USA) by medical insurance provided by:
Name of Insurance Company _____________________________________________ Policy Number _________________________

Address of Insurance Company ___________________________________________________________________________________

City State or Country ZIP/Postal Code ________________________
(iii) if I did not complete (ii) above, I hereby certify that Player is not covered by medical insurance nor by medical insurance that provides coverage for illness and/or injury occurring in the USA, and I agree that I am fully responsible in all respects, including, without limitations, any financial obligations, for any medical services/treatment rendered for illness/injury suffered by Player before, during, or after the Dr Pepper Dallas Cup XXXVIII, April 9 – April 16, 2017 in Dallas, Texas, USA, and I agree that payment or arrangement for payment for said medical services/treatment will be made to/with the provider at the time service is rendered to Player.
Also, by my signature below, I hereby give my consent and permission for the Player to be medically and/or surgically treated for injuries and/or illness of any kind or seriousness. Further, I give my consent and permission to the physician and/or hospital and/or other health care provider selected to provide medical or surgical treatment, including, without limitation, dental care, hospitalization, injection, anesthesia, invasive surgery or any other form or kind of medical or surgical care (emergency or otherwise) for the Player. Further, I give my consent and permission to Dallas Cup, Inc., North Texas State Soccer Association, and their affiliates, subsidiaries, successors, assigns and licensees, to use the Player’s name and photographic likeness in all forms and media for advertising, trade, and any other lawful purpose.
I am signing this agreement/authorization in my individual capacity and on behalf of Player (a minor child) named above, of whom I am parent or legal guardian. (If this document is signed by two persons, each agrees that they are jointly and severally responsible for the obligations stated herein.)
______________________________________________________________________________________________________________

Print Full Name Signature of Parent/Guardian (circle one) Date of Signature

______________________________________________________________________________________________________________

Residence Address City, County, State and Country

______________________________________________________________________________________________________________

Print Full Name Signature of Parent/Guardian (circle one) Date of Signature

______________________________________________________________________________________________________________

Residence Address City, County, State and Country

_______________________________________________________

Team Name and Age Group
DISTRIBUTION: ORIGINAL - TEAM REPRESENTATIVE COPY – TO DALLAS CUP OFFICE BY REQUIRED DEADLINE
1/3/2017