Player s Full Name: Date of Birth: Height: Weight: Age: High School Name: Primary Position Played: Secondary Position (if any):

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1 Circle the state in which your high school is located. Circle your T-Shirt size: S M L XL XXL 3XL Player s Full Name: Date of Birth: Height: Weight: Age: High School Name: Primary Position Played: Secondary Position (if any): PLAYER Player Cell Number: Parent/Guardian Number: Address (most often checked): Instagram Twitter Mailing Address: City: State: Zip Code:

2 PLEASE READ THIS DOCUMENT CAREFULLY BEFORE SIGNING EACH SECTION. THIS IS A LEGALLY BINDING DOCUMENT. The following releases, waivers and medical information forms require parent/guardian signature in each section if the Border Bowl participant is under the age of 18. HOLD HARMLESS WAIVER AND RELEASE I/We,, the undersigned, understand that by participating in the WJBF Sports and Augusta Chronicle Border Bowl Football Combine/Game/Cheerleading activities, I am/ my/our child is exposing myself/himself/herself to the risk of serious injury and/or death. By my/our signature(s) below I/We release and waive, and further agree to indemnify, hold harmless or defend Nexstar Media Group, Inc. d/b/a WJBF-TV, GateHouse Media d/b/a The Augusta Chronicle, the WJBF Sports and Augusta Chronicle Border Bowl Committee, Athelite Sports Training Academy, LLC, any governing body of education which provides a venue for Border Bowl/ any Border Bowl-related events, any governing body of education that has participants represented at the combine/game/cheerleading activities, Johannsen Sporting Goods, and each of their parent or affiliate companies, sponsors, individual members, employees, representatives, agents, successors and assigns (collectively, the Border Bowl Entities ), from and against any and all claims that I/We or my/our child may have or claim to have, known or unknown, directly or indirectly, for any losses, damages, injuries, or adverse reactions arising out of, during, or in connection with my or my/our child s participation in the WJBF Sports and Augusta Chronicle Border Bowl Football Combine/Game/Cheerleading Activities. I/We agree that a photocopy or facsimile of this document shall be considered the same as the original document. By my/our signature(s) below, I/We certify that I/We have read and understand this release agreement. AUTHORIZATION AND CONSENT FOR EMERGENCY TREATMENT I/We,, the undersigned, do hereby give my/our consent to my / my/our child s participation in all activities related to the WJBF Sports and Augusta Chronicle Border Bowl Football Combine/Game/Cheerleading. I/We agree that if it is determined that I / my/our child needs medical or dental treatment while participating in the WJBF Sports and Augusta Chronicle Border Bowl Football Combine/Game/Cheerleading, I/We will be financially responsible for any treatment determined to be necessary by a physician, dentist, certified athletic trainer, emergency medical personnel, or any other medical personnel. I/We give permission for the WJBF Sports and Augusta Chronicle Border Bowl Football Combine/Game/Cheerleading medical staff to care for and provide appropriate medical treatment for me / my/our child in the event of an injury/illness. By my/our signature(s) below, I/We certify that I/We have read and understand this release agreement. I/We agree that a photocopy or facsimile of this document shall be considered the same as the original document.

3 AUTHORIZATION FOR RELEASE/RECEIPT OF MEDICAL INFORMATION I/We,, the undersigned, hereby authorize the Border Bowl Entities, to use or disclose my/ my/our child s health information in their possession to Designated Border Bowl Game/Combine/Cheerleading Medical Trainers and/or EMS Services, including without limitation any protected health information (as defined by federal and state law). I/We understand that this authorization is voluntary. I/We also understand that if the person or entity authorized by this document to provide or receive my / my/our child s health information is not a health plan or health care provider, then the disclosed information may no longer be protected from further disclosure by federal and state law. By my/our signature(s) below, I/We certify that I/We have read and understand this release agreement. I/We agree that a photocopy or facsimile of this document shall be considered the same as the original document. TELEVISION/PHOTO/DATA RELEASE & AUTHORIZATION I/We, the undersigned do hereby consent to being filmed / my/our child being filmed (still or video) in connection with the WJBF Sports and Augusta Chronicle Border Bowl Football Combine and The WJBF Sports and Augusta Chronicle Border Bowl Football Game and related activities and /or for advertising, promotional or informational purposes related thereto. I hereby authorize the Border Bowl Entities to record my / my/our child s name, likeness, image, voice and participation in the WJBF Sports and Augusta Chronicle Border Bowl Football Combine and The WJBF Sports and Augusta Chronicle Border Bowl Football Game and related activities on film, tape or otherwise for use in the Border Bowl Entities sole discretion. I understand and agree that any film taken of me / my/our child may be edited and otherwise altered at the sole discretion of the Border Bowl Entities, and used and re-used by the Border Bowl Entities, in whole or in part, for any and all broadcasting, advertising, home media products, digital distribution, or exploitation of any type, whether audio or visual, or for any purpose in any format or media (whether now known or hereafter devised), in perpetuity, throughout the world. By signing this release, I understand that I have / my/our child has no rights to any program or advertisement that may include my / my/our child s name, image, voice, likenes s, or bio, and no right to receive any compensation or consideration for any uses by the Border Bowl Entities. I also grant the Border Bowl Entities the right to use any data obtained for purposes of print and electronic publication, broadcast, and writing studies/research for publication. By my/our signature(s) below, I/We certify that I/We have read and understand this release agreement. I agree that a photocopy or facsimile of this document shall be considered the same as the original document.

4 Player Name: Date of Birth: Home Mailing Address: City: State/Zip: Father/Guardian Name: Mother/Guardian Name: Emergency Contact: Primary Relationship: Alternate Head Coach Name: School Primary Family/Team Physician Name: MEDICAL INSURANCE INFORMATION Do you have a private medical insurance plan? YES / NO Medicaid/Partners for Health? YES / NO Medicaid Number: Medical Insurance Company: Address: Policy Holder s Name: Group Name or #: Policy or Contract #: Are you currently covered by a Secondary Athletic Insurance Policy through your school? YES / NO

5 MEDICAL HISTORY The following questions are intended to provide the WJBF Sports & Augusta Chronicle Border Bowl Combine/Game/Cheerleading Medical Staff background regarding your medical history. Please check YES or NO Explain ALL Yes answers in the space provided. Yes No Are you/your child currently taking any medications? Yes No Are you/your child allergic to any type of medications? Yes No Are you/your child allergic to any insects/foods/materials, etc.? Yes No Do(es) you/your child have any past or present medical condition(s) that could impact your/his ability to participate in the WJBF Sports & Augusta Chronicle Border Bowl Combine/Game? Please use the space below to provide any additional information you feel is essential to your/your child s well-being and our ability to provide quality health care for you during your time with the WJBF Sports & Augusta Chronicle Border Bowl Football Combine/Game/Cheerleading. **This form must be signed by a parent/guardian if the participant is under 18 years old.** I,, the undersigned, do hereby represent and warrant to Nexstar Media Group, Inc. d/b/a WJBF-TV and GateHouse Media d/b/a The Augusta Chronicle that the information presented above is complete and accurate to the best of my knowledge, and that there are no other facts or medical conditions known to me that would impact my/my child s ability to participate in the WJBF Sports & Augusta Chronicle Border Bowl Football Combine/Game/Cheerleading. I hereby completely and fully release Nexstar Media Group, Inc. d/b/a WJBF-TV and GateHouse Media d/b/a The Augusta Chronicle and its affiliates from any and all claims that I/my child may have that arise out of or are related to my/my child s participation in the WJBF Sports & Augusta Chronicle Border Bowl Combine/Game/Cheerleading. Signature of Parent/Guardian