Registration Form

Participants name _______________________ Birthdate ______________ Age_____________

Grade (Fall 2012) __________________________ Sport(s) ______________________________
School (Fall 2012) _______________________________________________________________
Address _______________________________________________________________________
Parent/Guardians name _____________________________Email _______________________
Home phone ______________________________ Cell Phone ___________________________
Where did you find out about camp? _______________________________________________

Please read and sign the following Waiver / Medical Release:

I hereby give my permission for any and all medical attention necessary to be administered to
my child in the event of an accident, injury, or illness. I authorize Justin Gordon to request
medical treatment as necessary to insure the well being of my child. I also hereby waive and
release Justin Gordon from liability for injuries that may occur during training. I also understand
that Justin Gordon retains the right to use photos taken during training sessions for public
and/or advertising purposes.
Parent / Guardian Signature: _______________________________ Date: __________________