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2nd Annual McClure Middle

Dodgeball Tournament
March 10, 2016
4:00 pm – 7:00 pm
Student Player’s Name:
Team Name:

Team Captain:


Homeroom teacher:

Student Parent’s Name:
Parent’s Cell Number:
Parent Email Address:
Cost is $5 per registrant. Checks should be made payable to SMMS PTSA. Please place
registration form and fee in plain envelope and leave with your homeroom teacher with
“Dodgeball” written on outside.
“Having been made aware of the activities the registrant will be doing, I hereby consent to the registrant’s participation in the
dodgeball tournament at McClure Middle School. I voluntarily release and discharge SMMS or SMMS PTSA from any and all
liability, claims, actions, or rights of action which are in anyway related to the registrant’s participation in the tournament. I agree
to indemnify and hold SMMS or SMMS PTSA harmless from any and all costs or damages, including attorney fees, incurred in
connection with the registrant’s participation in the tournament. I further agree not to sue, assert or otherwise maintain any
claim or cause of action against SMMS or SMMS PTSA arising from the registrant’s participation.
In case of emergency, I understand every effort will be made to contact parents or guardians. However, if parents or guardians
cannot be reached, I hereby give SMMS PTSA or SMMS permission to act on my behalf in seeking and administering medical
treatment in the event that such treatment is deemed necessary. I release SMMS and SMMS PTSA from liability in acting on my
behalf in this regard and rendering such medical treatment.”

Print name:
Emergency contact name:
Day phone:

PTSA Use Only: □ Cash □ Check #___________ Completed By: _______________