Sports Camp Registration and Medical Release Form

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Please complete the following information and submit this form to sign your child up for our Sports Camp
Date: July 30 - August 3
Time: 3:30 - 6:30
Place: Pine Valley Park
Cost: $25 (3rd child and each subsequent = $20 each)

Email *

SELECT YOUR CHOICE *

ULTIMATE FRISBEE (Ages 8-13)

SOCCER (Ages 6-13)

CHEER (Ages 8-13)

BASKETBALL (Ages 8-13)

TEAM 45 (All kids 4-5 years old)

SELECT YOUR SHIRT SIZE *

Please list the size shirt needed for your child and/or children. Youth(Y), Adult (A) Sizes: YS, YM, YL, AS, AM, AL

CHILD/CHILDREN(S) NAME(S) *

Please list each Child's/Children's Name and include the Gender of your child and or Children by typing an M or an F next to their name below.

AGE *

Please list the name and ages of your child and/or children

GRADE (going into in the fall) *

Please list the grade for each of your children that you are registering for Sports Camp

Date of Birth *

Please include the dates of birth for all children registering for Sports Camp

Address *

Please include City, State, and Zipcode

Home Phone *

Cell/Daytime Phone Number *

Parent(s) Name: *

Emergency Contact Name and Phone Number *

Allergies *

Health Issues

Medical and Liability Release:

We realize that no activity is without possibility of unforeseen hazards, which could result in injury to an individual. As a parent or guardian, you are to be aware of your responsibility to instruct your child of the importance of conduct, which will insure safety and enjoyable time while participating in this activity. By signing this form, you , as a parent, guardian, or other responsible party, agree to assume the risks and hazards, which are inherent in this kind of activity. You also agree to absolve and find harmless the sponsoring organizations and their representatives for damage, loss, or injuries to the child for whom you sign.

I further give my permission for the use of any photo or likeness of my child to be used by the sponsoring organizations for their use in promotional materials.

Parents are responsible for care of children before and after Sports Camp hours.

CHILD/CHILDREN'S NAME(S) *

By completing this section you are hereby giving permission to your child permission to participate in this activity, and you are giving permission to the leaders of this function to authorize any treatment deemed necessary by a licensed physician due to accident or illness during this activity.

Parent's/Guardian Print Name *

Today's Date *

YYYY

Send me a copy of my responses.

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