* $25 charge for all returned checks

* By completing this form I understand that I am responsible to make payment of $60.00 to the JT Dorsey Foundation prior to participating in this event

* mailed in forms can be sent to

The JT Dorsey Foundation
1014 Cherrington Dr
Harrisburg, PA 17110

* I consent that photographs taken of my child are the property of the JT Dorsey Foundation and may be reproduced and publicized as the JT Dorsey Foundation desires at any time, free of claims on my part. I also assent that I am the child's legal guardian and have the right to consent.

I give permission for my child to participate in all Skill School activities. He/she is in good health and may participate in normal program activities unless I specify otherwise to the JT Dorsey Foundation staff. I agree not to hold the JTDF and or the facility responsible for injuries to my child's person and/or property while participating in the program and or any activities associated with it. In case of medical emergency, I authorize the staff of the JTDF to seek emergency care for my child. I understand that medical information and personal data will be used in programs, when necessary, to protect my child's well being, but will be kept confidential by the JTDF staff.

RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY AND PARENTAL CONSENT AGREEMENT  ("AGREEMENT"):  IN CONSIDERATION of being permitted to participate in any way in the soccer activity ("Activity") I, for myself for personal representatives, assigns, heirs, and next of kin:  1. ACKNOWLEDGE, agree, and represent that I understand the nature of soccer Activities and that I am qualified, in good health, and in proper physical condition to participate in such Activity. I further agree and warrant that if at any time I believe conditions to be unsafe, I will immediately discontinue participation in the Activity.  2. FULLY UNDERSTAND THAT: (a) SOCCER ACTIVITIES INVOLVE RISKS AND DANGERS OF SERIOUS BODILY INJURY, INCLUDING PERMANENT DISABILITY, PARALYSIS, AND DEATH ("RISKS");  (b) these Risks and dangers may be caused by my own actions or inaction's, the actions or inaction's of others participating in the Activity, the condition in which the Activity takes place, or THE NEGLIGENCE OF THE "RELEASEES" NAMED BELOW; (c) there may be OTHER RISK AND SOCIAL AND ECONOMIC LOSSES either not known 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 my participation or that of  the minor in the Activity.  3. HEREBY RELEASE, DISCHARGE, AND COVENANT NOT TO SUE THE JT DORSEY FOUNDATION, RED ROSE ARENA or CENTRAL PENNSYLVANIA SOCCER LEAGUE., their respective administrators, directors, agents, officers, members, volunteers, and employees, other participants, any sponsors, advertisers, and, if applicable, owner and lessors of premises on which the Activity takes place, (each considered one of the "RELEASES" herein) FROM ALL LIABILITY, CLAIMS, DEMANDS, LOSSES, DAMAGES ON MY ACCOUNT CAUSED OR ALLEGED TO BE CAUSED IN WHOLE OR IN PART OF NEGLIGENCE OF THE "RELEASEES" OR OTHERWISE, INCLUDING NEGLIGENT RESCUE OPERATIONS AND I FURTHER AGREE that if, despite this RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK, AND INDEMNITY AGREEMENT 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 litigation expense, fees, loss, liability, damage, or cost which may incur as the result of such claim.  I HAVE READ THIS AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT AND HAVE SIGNED IT FREELY AND WITHOUT INDUCEMENT OR ASSURANCE OF ANY NATURE AND INTEND IT TO BE A COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE GREATEST EXTENT 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.  MINOR RELEASE:  AND I, THE MINOR'S PARENT AND/OR LEGAL GUARDIAN, UNDERSTAND THE  NATURE OF SOCCER ACTIVITIES AND THE MINOR'S EXPERIENCE AND CAPABILITIES AND BELIEVE THE MINOR TO BE QUALIFIED, IN GOOD HEALTH, AND IN PROPER PHYSICAL CONDITION TO PARTICIPATE IN SUCH ACTIVITY. I HEREBY RELEASE, DISCHARGE, COVENANT NOT TO SUE, AND AGREE TO INDEMNIFY AND SAVE AND HOLD HARMLESS EACH OF THE RELEASEE'S FROM ALL LIABILITY CLAIMS, DEMANDS, LOSSES, OR DAMAGES IN THE MINOR'S ACCOUNT CAUSED OR ALLEGED TO BE CAUSE IN WHOLE OR IN PART BY THE NEGLIGENCE OF THE "RELEASEES" OR OTHERWISE, INCLUDING NEGLIGENT RESCUE OPERATION 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 RELEASEES NAMED ABOVE, I WILL INDEMNITY, SAVE, AND HOLD HARMLESS EACH OF THE RELEASEES AGAINST ANY LITIGATION EXPENSES, ATTORNEY FEES, LOSS LIABILITY, DAMAGE, OR COST THAT MAY INCUR AS THE RESULT OF ANY SUCH CLAIM.