Bowling Clinic Registration Form and Media / Press Release

camps@dirupobowling.com
973-945-8222
Bowling Clinic Registration Form and Media / Press Release
Date of Session*

MonthDayYear
Date
Location of Camp, Clinic*
Name*

First NameLast Name
Email*
example@example.com
Phone Number*

Area CodePhone Number
Emergency Contact*

First NameLast Name
Emergency Contact Phone Number*

Area CodePhone Number
Physical Limitations*
Years Bowling*
What would you like to learn during this session?*
Media / Press Release

I hereby consent to the use of my, or my child's, likeness, picture or voice to be released to the following media (please select yes or no to each media format). Such uses will not be viewed as endorsement by me/my child of any product or service. I hereby indemnify the organization responsible, and their licenses, respecting any claims arising out of any acts or statements.
NEWSPAPERS (ANY AND ALL PUBLICATIONS THAT WILL PROMOTE THE SPORT OF BOWLING.)*

YesNo
WEBSITE WWW.DIRUPOBOWLING.COM & ALL MEDIA RELATIONS TO DIRUPO BOWLINGBOWLING CENTER MEDIA*

YesNo
VIDEO TAPING (VIDEO ANALYSIS AND WEBSITE VIDEO)*

YesNo
By signing below, I acknowledge that at the Bowling Clinic, the participant will participate in a sport that may involve, among other things, physical contact of the body with other persons or objects, including the bowling balls and the bowling alley, he/she may incur a risk of injury. I specifically waive, give up and release DiRupo Bowling Camps and staff, Ron Clifton, and/or the bowling facility and staff from liability for any claim for damages which the participant may have for injuries or illness that he/she may sustain at camp.

I also hereby consent to the use of my, or my child's, likeness, picture or voice to be released to the media outlets checked above. Such uses will not be viewed as endorsement by me/my child of any product or service. I hereby indemnify the organization responsible, and their licenses, respecting any claims arising out of any acts or statements.
Signature of Attendee*

Clear
Printed Name of Attendee*

First NameLast Name
Signature of Guardian if Attendee is under the age of 18.

Clear
Printed name of Guardian if Attendee is under the age of 18.

First NameLast Name
Today's Date*

MonthDayYear
Date
Method of Paymet*

Credit CardMailing CheckCash on day of event

My Products

2 day camp$350.00

1 Day Clinic Adult$100.00

1 Day Clinic Youth$80.00

Enter coupon

Total $0.00

Payment Methods

Debit or Credit Card

First Name	Last Name
Credit Card Number	Security Code
Card Expiration

Please click one of the PayPal options to complete payment and submit the form.

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