Participant Waiver Statement


PO Box 305

Belvidere, NJ 07823

(908) 362-7005

Roster Participation Waiver for Team Members of : _____________________ (Company Name)

In consideration for the Morris County Industrial Recreation Association, Inc. (MCIRA) permitting me on a ____________ team in the MCIRA League, I hereby agree and/or represent the following:

I am in good mental and physical health.

  1. I understand that there may be some risks involved in my participation in the above sporting activity, including but not limited to those associated with weather conditions, playing conditions, equipment, and other participants.
  2. I fully assume the risk associated with the participation in said sporting activity.
  3. I hereby waive any and all claims that I may have against MCIRA, its directors, officers, supervisors, umpires, referees or other employees or agents arising out of any personal injury or property damage that is incurred during said participation, whether active or inactive.

Note: Each team member must read and understand the above conditions and representations prior to signing this form. Please duplicate if your team exceeds 20 players.

1   1  
2   2  
3   3  
4   4  
5   5  
6   6  
7   7  
8   8  
9   9  
10   10  
11   11  
12   12  
13   13  
14   14  
15   15  
16   16  
17   17  
18   18  
19   19  
20   20  

I hereby acknowledge that each individual has read and understands the above conditions and representations. I also verify that each individual is the person who signed the foregoing roster and did so voluntarily.

_______________________________________ ______________________________

(Company You Are Employed By) (Print Team Captain's Name)


(Team Captains Signature)

State of New Jersey SS

County of

On this day of , ______ , before me, the team captain, personally appeared, who, I

am satisfied, is the person who signed the foregoing instrument, and he/she did acknowledge

that he/she signed and delivered the same as his/her voluntary act and deed, for the uses and purposes expressed in the instrument.

__________________________________________ (Signature of Notary Public)