Participant Waiver Statement
PO Box 305
Belvidere, NJ 07823
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.
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.
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
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)