Competition Form

COMMUNITY SPORTS DAY REGISTRATION

SATURDAY, JUNE 29th, 2024
Participant Information
Which camp do you plan to attend?
Camper's Name*

First NameLast Name
Campers School*
Birthdate:*

MonthDayYear
Gender*
Grade Level:*
Shirt Size:*
Guardian / Parents Name: (under 18)

First NameMiddle NameLast Name
Parent's Phone*
Format: (000) 000-0000.
E-mail*
Who is the emergency contact?*
Guardian's Phone*
Format: (000) 000-0000.
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Running BackOffensive LineLine BackerDefensive LineQuarter BackDefensive BackWide ReceiverKicker
How would you rate your current skill level:

1

2

3

4

5

1 is Beginner, 5 is Advanced
Individual TrainingGroup TrainingYouth LeagueSummer Camp
Camp Volunteer Reservation (Adults Only)
RefereeSpeakerSkills TrainingMentoringCoachingVolunteerMascotHands-on Support
Emergency Contact & Health Insurance Information
Emergency Contact's Name*

First NameLast Name
Relationship*
Phone Number*
Format: (000) 000-0000.
YesNo, I'll pay with cash.
Insurance Carrier*
Insurance Phone Number*
Format: (000) 000-0000.
Name of Policy Holder*
Subscriver ID/Group Number
Card Number / Card Date
YesNo
Please describe*
Name of Physician / Emergency Medical Care Facility
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Format: (000) 000-0000.
Parental Permission For Emergency Treatment

In the event of illness or accident, I give my permission for emergency treatment by qualified medical personnel for my child, and I authorize the person in charge to take my child to secure any and all necessary emergency medical care for my child.
Release of Liability

Although the safety of all sports activities is the primary concern, some outdoor or indoor sports activities at certain facilities may cause injuries and/or death. I expressly assume the risk of injury, death, and/or illness arising from any cause, and agree to waive the right to pursue any claim against Edward and Annie Lee Keyes Foundation and its representatives. I understand all entry fees are non-refundable.
Medical Insurance Information:
YesNo
YesNo
Parent Signature
Date

MonthDayYear
Date
To complete registration, please click Submit form. You will receive a confirmation email. If you do not receive the email within a five minutes, please check your spam.
Should be Empty:

Participant Information

Medical Insurance Information: