Name:_______________________________________

Home Phone: (______)_____________________

Address: _____________________________________

Work Phone: (______)______________________

City: _________________________ Zip:____________

E-mail:_________________________________

Birthdate (if under 21) _____________

Experience (years): Coaching_______ Playing______

I would be willing to serve as a:

_____ Head Coach (Must commit to two practices and one game per week)

_____ Assistant Coach

_____ Team Coordinator (Snack list, phone chain, administrative duties, etc)

School you will be volunteering at: ______________________________________________________________

 I would like to coach the following grade division: (Grade for 2008-09 school year)

Sr. Pre – K __________              1^st -2^nd grade __________

 3^rd -4^th grade __________           5^th -6^th grade __________

Days of the week I CAN NOT practice: ____Mon    ____ Tue    ____Wed   ____ Thu   ____Fri

INFORMED CONSENT AND RELEASE: I, the undersigned, inconsideration of the request and permission to participate in Junior Premier Sports Corporation Volunteer Program, hereby assume full responsibility for all risk of injury or loss which may result from my participation in this activity and hereby AGREE TO DEFEND, INDEMNIFY, HOLD HARMLESS, RELEASE AND FOREVER DISCHARGE Junior Premier Sports Corporation, its respective officers, agents and employees, past and present, from any and all acts of negligence and all claims and demands whatsoever, which the undersigned, any third person, or any persons acting under their behalf, have or may have against Junior Premier Sports Corporation, or its respective officers, agents or employees, past and present, by reason of any accident, illness, injury to or death of any person or persons, or damage to or loss or destruction of any property arising or resulting directly or indirectly from participation in the referenced activity and occurring during said participation, or any subsequent thereto. The terms of this release will serve as a release and assumption of risk for my heirs, executors and administrators and for all of my family members. I agree and acknowledge that some activities may be of a hazardous nature and/or include physical and/or strenuous exercise or activity, and, understanding this, I state that to the best of my knowledge, I have no medical, physical, mental or emotional health condition which would hinder or prevent my active participation in the referenced activity. PLEASE NOTE: No medical insurance or insurance coverage of any kind is provided by Junior Premier Sports Corporation. Junior Premier Sports Corporation strongly recommends that each participant have some type of accident medical insurance for his/her own protection.

PARENT OR GUARDIAN MUST SIGN IF VOLUNTEER IS UNDER 18 YEARS OF AGE.

Signature _________________________________________________ Date ___________________

Print this form fill it out and mail it to:
Attn:JPS Volunteer
P.O. Box 566507 Miami FL 33256