I, the parent/guardian of the registrant, certify that my child is in good physical condition and can participate in this program. Recognizing the possibility of physical injury associated with soccer, exercise and/or physical fitness training, I hereby release, hold harmless and agree to indemnify, potentiALL, Jen Enterprises 1 LLC, Jennifer Walters, Lea Westlake, and all associated parties, including the owners of the fields and facilities used for the program, from any and all liability of every nature, kind and description as a result of any injuries, hurt or damage sustained by registrant as a result of his/her participation in this program.
I further grant potentiALL parties the right to use the registrant’s name, picture and/or likeness in printed, broadcast, web based and other material concerning the program provided such use is related to the registrant’s status as a participant in the program. Furthermore, as parent or legal guardian of the above named registrant, I hereby give my consent for emergency medical care prescribed by a duly licensed Doctor of Medicine or Doctor of Dentistry. This care may be given under whatever conditions are necessary to preserve the life, limb or well-being of my dependent.