King Joes Barbell Club

YOUTH PROGRAM WAIVER                                

KING JOE’S BARBELL CLUB                                                                      

622  E. Drinker St

Dunmore  Pa 18512

(570)-241-4548

_______ BOY _______GIRL

_______ Weightlifting

Participant’s Name________________________________________________________________

Street_______________________________________Town______________________________

Zip Code_________________ Phone #____________________________

Date of Birth______________ Age________________________________

Shirt Size (for selected programs) (Child Sizes) S M L

                                                    (Adult Sizes) S M L XL

Waiver In Case of Injury

As the parent/guardian of the above participant, I hereby volunteer to relinquish any right

to claim against KING JOE’S BARBELL CLUB or its elected officials or employees, any damages to property or personal injury that may be incurred or suffered during participation in scheduled games or in the practices taking place on the designated gym, etc.. used by the program, unless such damage to property or person shall be incurred or suffered through the negligence of the KING JOE’S BARBELL CLUB and its elected officials, employees or appointees.

I, the parent/guardian of the above mentioned athlete, give my permission for my son/daughter to participate in the above mentioned activity and fully understand the stipulations of

the contract.

Parent/Guardian

Signature_______________________________________Date_____________________________