PAL Summer Volleyball Camp

Registration Form

Camp Participant:  ___________________________________________________CAMP     I      II

Address:  ________________________ _________________________________
Town__________ _________________________________Zip _______________

School:  ________________________________________ GRADE.______ ______

Volleyball experience_________________________________________________

Parent/Guardian:

Name: _______________________________________________________________

Home Phone:  ______________ Work Phone:  _____________Cell Phone: ____________

Parent/Guardian email: ___________________________________________________

In case of emergency, contact:

Name:  ______________________Relationship: ___________________

Home Phone: ____________ Work Phone: _________ Cell Phone: _______

Primary Insurance Co. __________________Primary Group/Policy # ________________

Does policy cover sport related accidents? ______ Yes ______ No

Any medical concerns?  _____________________________________________

Volleyball Camp Release

In consideration of being allowed to participate the undersigned acknowledges, appreciates, and agrees that:

1.  The risk of serious injury does exist.

2.  My child knowingly and freely assumes such risks.

3.  My child willingly agrees to comply with the stated and customary terms and conditions for participation.  If she observes any unusual hazard during participation, she will remove herself from participation and bring such to the attention of the nearest supervisor.

4.  I approve of my child’s attendance at the Danbury/Newtown Summer Volleyball Camp and release and hold harmless Danbury/Newtown Volleyball camp and their employees.  I certify that my child is in good health and able to participate in the programs’ activities. 

I am ___ am not ___ attaching a note explaining special physical limitations and/or required medication, if any.

If, during the course of my daughter’s activities in volleyball, she should become ill or sustain an injury, I hereby authorize you_______ I do (not) authorize you_______

to obtain emergency medical/dental care. I will assume financial responsibility for the bills incurred through my insurance company.

Parent/Guardian (PLEASE PRINT) _________________________________________

Signed: (Parent/Guardian) _________________________ Date: _________________

Any questions contact Tom Czaplinski 203–395-5231 or John MacMillan 203-746-4194