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Emergency Authorization Form

Emergency Authorization Form

Chantilly Youth Association




Print Player


Date  of Birth

Parent SignAture



Coach’s Printed Name __________________________ League_____________________ Age Group: Under______ Boys / Girls

I, the undersigned parent or guardian of the above named participant, a minor, do hereby authorize the coaches, assistant coaches, or parents of team member acting in the capacity of activity supervisors/vehicle drivers, as Agents for the undersigned, to consent to emergency medical, surgical or dental examination, treatment, etc., until a parent or legal guardian can be contacted.  I will not hold these persons legally or financially responsible in any way.  I understand that the Chantilly Youth Association does not carry accident insurance. I also acknowledge that various private and public landowners (“Owners”) have agreed to allow CYA to use certain real property owned by the Owners (“the property”) for athletic activities, that Owners will not be providing any supervisory personnel or other services for such athletic activities or the property, and that Owners shall have no responsibility for supervision, maintenance or repair of the property. In addition, the undersigned fully understands the risks inherent in participating in athletic activities and agrees to assume the risk of injury and harm and further agrees that Owners shall have no responsibility or liability for any injury, harm or any other damage that may occur on the property. 

(CYA 3/16/01)