Registration Form

Registration Form

Please fill out all required fields and upon completion, hit submit. It is recommended that you print a copy of this form for your records.
Choose the type of camp you would like to attend:
There are three (3) Gridiron Group Sessions to choose from. Each session consists of five (5), one-hour classes.

1st Session "Lightning Fast": 1/20 1/27 2/3 2/10 2/17 (On or before 1/7: $95; after 1/7: $145)

2nd Session "Lock Down": 2/24 3/3 3/10 3/17 3/24 (Single session: $145)

3rd Session "Show Time": 4/7 5/4 5/11 5/18 5/25 (Single session: $145)

Camp Times

9:00am - 10:00am Ages 7, 8, 9, & 10

10:15am - 11:15am Ages 11, 12, 13 & 14

PrePaid Multiple Session Discounts

Until 1/7/2013:

session #1 only: $95

session #1 and #2 or #3: $230

session #1 and #2 and #3: $365

session #2 only: $145

session #2 and #3: $270

session #3 only: $145

After 1/7/13:

1 session: $145.00
2 sessions: $270.00

3 Sessions: $405.00
How many sessions would you like to attend?
Please select your choice of session:
Please select your choice of sessions:
Your total for the number of sessions selected is $95.00. Please fill out the form below for registration. You will be charged this amount to the credit card you provide.
Your total for the number of sessions selected is $145.00. Please fill out the form below for registration. You will be charged this amount to the credit card you provide.
Your total for the number of sessions selected is $230.00. Please fill out the form below for registration. You will be charged this amount to the credit card you provide.
Your total for the number of sessions selected is $230.00. Please fill out the form below for registration. You will be charged this amount to the credit card you provide.
Your total for the number of sessions selected is $270.00. Please fill out the form below for registration. You will be charged this amount to the credit card you provide.
Your total for the number of sessions selected is $365.00. Please fill out the form below for registration. You will be charged this amount to the credit card you provide.
Player's Name:

First NameLast Name
Age as of Session Start:
Parent's Name:

First NameLast Name
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
E-mail:
Confirm E-mail:
Cell Phone Number:

Area CodePhone Number
School as of Session Start Date:
Grade as of Session Start Date:
Last Year's Coach and Chapter:
Payment Method (Select ONE):
Cardholder Name as listed on the card:

First NameLast Name
Card Number:
Confirm Card Number:
Expiration Month
Expiration Year
Card Billing Address (if different from above):

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
MY SON HAS MY PERMISSION TO ATTEND THE GRIDIRON ACADEMY FOOTBALL CAMP. I CERTIFY THAT WITHIN THE PAST TWO YEARS HE HAS PAST A

PHYSICAL EXAMINATION AND THAT NOW HE IS PHYSICALLY ABLE TO PARTICIPATE IN FOOTBALL CAMP ACTIVITIES WITHOUT RESTRICTIONS. IN THE EVENT OF

ILLNESS OR INJURY, I GIVE MY CONSENT FOR MEDICAL TREATMENT AND PERMISSION TO ATTENDING PHYSICIAN TO HOSPITALIZE, SECURE PROPER TREATMENT,

AND ORDER INJECTIONS, ANESTHESIA, OR SURGERY. I WILL BE RESPONSIBLE FOR MEDICAL OR OTHER CHARGES IN CONNECTION WITH MY SON’S ATTENDANCE

IN CAMP.

I ACKNOWLEDGE THAT AT THE GRIDIRON ACADEMY MY SON WILL PARTICIPATE IN A SPORT THAT MAY INVOLVE, AMONG OTHER THINGS, PHYSICAL CONTACT

OF THE BODY WITH OTHER PERSONS OR OBJECTS, INCLUDING THE GROUND AND THAT AT THE GRIDIRON ACADEMY, HE MAY INCUR A RISK OF INJURY. I

SPECIFICALLY WAIVE, GIVE UP AND RELEASE THE GRIDIRON CAMP AND STAFF FROM LIABILITY FOR ANY CLAIM FOR DAMAGES, INJURIES OR ILLNESS THAT HE

MAY SUSTAIN AT THE GRIDIRON ACADEMY CAMP. CANCELATIONS MUST BE RECEIVED IN WRITING. NO REFUNDS FOR CANCELATIONS RECEIVED WITHIN

6 DAYS OF THE 1ST DAY OF THE SESSION.
Medical Insurance Carrier:
Primary Insured:
Policy/Carrier/Group #:
Authorized Name:
Today's Date:

MonthDayYear
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