FUTURE COUGAR CAMP

MEDICAL RELEASE FORM

 

_________________________________ _____________________

  Name of Camp Participant (Please Print)Participant’s Date of Birth

  _______________________________________________________

  Name of Parent/Guardian (Please Print) Relation to Camp Participant

  _________________________________ _____________________

  Home Address      City State Zip

  _______________________    _____________________

  Daytime Telephone Number   Evening Telephone Number

  _________________________________ _____________________

  Emergency Contact (Please Print) Relation to Camp Participant

  _________________________________

  Emergency Daytime Telephone Number

                                               PRE-EXISTING CONDITIONS

  HAS THE CAMP PARTICIPANT HAD, OR CURRENTLY HAVE, ANY OF THE FOLLOWING:

  Concussions YN Allergies       YN

  Joint/Bone Injury    YN Asthma YN

  Heart Condition     YN Surgery YN

Other medical conditions ______________________________________________________

  Medical Release

  In consideration for the opportunity to participate in the Future Cougar All Sports Camp, I voluntarily agree to assume all risks involved in my child’s participation in the Sports Camps and all related activities. I understand that if I allow my child to participate, my child may be exposed to risks of  personal injury and/or property damage or loss. I also recognize that there are both foreseeable and         unforeseeable risks of injury that may occur which the camp cannot specifically anticipate and list here.

  Release of Liability

  I release all members of the Future Cougar All Sports Camp from any and all liability, claims, costs, expenses, injuries, and/or losses that I or my child may sustain as a result of my child’s participation in the Future Cougar All Sports Camps. I certify by my signature below that I am this child’s parent or legal guardian. I sign this document freely and voluntarily.

           _________________________

           Parent/Guardian Signature Date

           __________________________

           Parent/Guardian Printed Name

                             NO CAMPER WILL BE ADMITTED TO CAMP UNLESS THIS FORM IS

                      COMPLETED, SIGNED, AND RETURNED TO CAMP PRIOR TO REGISTRATION