Camper’s Name: __________________________________________

 

Age the day camp begins: _______ 2008-2009 Grade level: _____                 School: _____________________________

Camper’s Address:  ___________________________________ City_______________ State_____ Zip: _______

 

Parent’s Email 1: ______________________________                          

 

Mother’s Name: _______________

                                  Home: (     ) __________ Cell: (     ) _________

 

Father’s Name:   _______________

                                  Home: (     ) __________ Cell: (     ) _________

 

Medical Insurance Information:

[  ] I DO NOT have medical insurance that covers my son and I agree to be fully liable for any and all medical cost incurred for treatment.

[  ] I DO have medical insurance for my son and I agree to be responsible for all costs that my medical insurance does not cover.

Camper’s primary insurance company: ___________________

 

Phone: (     ) ___________________

Policy holder's name:_________________                    

 

Relationship with camper:___________________

Policy/membership number:___________________                                                       Group name/number:_________________

 

Effective date of coverage: _____/_____/_____

I have read and I fully accept the terms and conditions described in the Camp Flyer, including the cancellation and refund policy. I understand that the Jaguar Youth Football Camp and the camp staff will do everything in their power to avoid any injury to all campers. I am fully aware that playing or practicing football or any sport involves risk of injury/illness. I understand that because of the nature of the sport contact and physical exertion will occur during this camp and that injury during practice at camp because of contact or physical exertion is possible. In return for my child (“Participant”) being allowed to participate in the camp, I release and agree not to sue any of the campers at the camp, Puyallup School District,  Emerald Ridge

Football Program and their staff members, sub-contractors, sponsors, agents, and affiliates from all present and future claims that may be made by the Participant or me, my family, estate, heirs, or assigns for property damage, personal injury, or wrongful death arising as a result of the

Participant’s participation in the camp and caused by the ordinary

negligence of the parties listed above, wherever, whenever, or however the same may occur.  I understand and agree that those listed above are not responsible for any injury or property damage arising out of the camp, even if caused by their ordinary negligence. I understand that participation in the camp involves certain risks, including, but not limited to, serious injury. I am voluntarily allowing the Participant to participate in the camp with knowledge of the danger involved and agree to accept all risks of such participation.

I certify that the Participant is in excellent physical health, and may

participate in strenuous and hazardous physical activities, including the football to be played in the camp. Permission is granted for Participant to receive emergency medical treatment, if needed. I also agree to indemnify and hold harmless those listed above for all claims arising out of

Participant’s participation in the camp and all related activities. I understand that this document is intended to be as broad and inclusive as permitted by the laws of the state in which the camp is taking place and agree that if any portion of the Agreement is invalid, the remainder will continue in full legal force and effect.  I am the parent or legal guardian of the Participant. I am of legal age and am freely signing this Agreement. I have read this form and understand that by signing this form, I am giving up legal rights and remedies. I represent that I am a parent/legal guardian of the child named above and I agree that the terms of this release are binding on me and the Child.

Parent/Legal Guardian

 

Signature____________________  Date_________

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