Please Complete The Following Form:
First Name
Last Name
Birth Date
Grade
Home Address
City
State
Zip
T-Shirt Size
Email
Position
High School
Emergency Contact Information:
Emergency Contact
Emergency Contact Relation
Emergency Contact Phone Number
Insurance Information:
Insurance Company
Policy Number
Group Number
Insured Name
Insurance Telephone Number
Guardian’s Consent and Indemnification Agreement:
	I am the Parent/Guardian of the above-named Participant who is under eighteen (18) years of age and am fully competent to sign this Agreement. In consideration of Participant being permitted to participate in the Activity and to use the program’s facilities and equipment, I hereby accept all risk to Participant’s health and of his injury or death that may result from such participation and I hereby release the above named Institution, its governing board, officers, employees, and representatives from any and all liability to Participant, Participant’s personal representatives, estate, heirs, next of kin, and assigns for any and all claims and causes of action for loss of or damage to Participant’s property and for any and all illness or injury to Participant’s person, including his death, that may result from or occur during Participant’s participation in the Activity, whether caused by negligence of the Institution, its governing board, officers, employees, or representatives, or otherwise. I further agree to indemnify and hold harmless the Institution and its governing board, officers, employees, and representatives from liability for the injury or death of any person(s) and damage to property that may result from Participant’s negligent or intentional act or omission while participating in the described Activity. I HAVE CAREFULLY READ THIS AGREEMENT AND UNDERSTAND IT TO E A RELEASE OF ALL CLAIMS AND CAUSES OF ACTION FOR PARTICIPANTS INJURY OR DEATH OR DAMAGE TO PARTICIPANT’S PROPERTY THAT OCCURS WHILE PARTICIPATING IN THE DESCRIBED ACTIVITY AND IT OBLIGATES ME TO INDEMNIFY THE PARTIES NAMED FOR ANY LIABILITY FOR INJURY OR DEATH OF ANY PERSON AND DAMAGE TO PROPERTY CAUSED BY PARTICIPANT’S NEGLIGENT OR INTENTIONAL ACT OR OMISSION.
	I HAVE READ THE ABOVE STATEMENT AND AGREE