Life Pacific Technique Summer Camp Registration Form

Life Pacific University Wrestling Camp Registration

IMPORTANT! : Before you submit the entire information, make sure all check marks are marked off that relate to you—including the days of camp you’re attending. If the form states the Total is $0 and you submit it, we will not receive your submitted form.
Athlete Information
Athlete's Name*

First NameLast Name
Birth Date*

MonthDayYear
Grade*
Current School*
Gender*

MaleFemale
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian Information
Name*

First NameLast Name
Home Number
Cell Number*
E-mail
example@example.com
Emergency Information
Emergency Contact's Name

First NameLast Name
Relationship
Phone Number*
Alt. Phone Number
Does the athlete have any allergies, chronic illness, or medical conditions? If yes, please describe. If none, please submit N/A.*
Is the athlete prescribed an inhaler? If yes, please explain any instructions. If none, please submit N/A.*
Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by Life Pacific University during the selected camp. In exchange for the acceptance of said child’s candidacy by Life Pacific University, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Life Pacific University and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected camp sessions.

In case of injury to said child, I hereby waive all claims against Life Pacific University . including all coaches and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in all sports activities, including wrestling. Some of these injuries include, but are not limited to, the risk of fractures, paralysis, or death.
Signature*

Clear
Medical Release and Authorization

As Parent and/or Guardian of the named athlete, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.

Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named athlete. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me.

Permission is also granted to Life Pacific University and its affiliates including Directors, Coaches, and Team Parents to provide the needed emergency treatment prior to the child’s admission to the medical facility.

Release authorized on the dates and/or duration of the registered season.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.
Signature*

Clear
Confirmation*

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
Signature*

Clear
Register Day(s):*
prevnext( X )
1-Day Registration
$50.00



2-Day Registration
$100.00



3-Day Registration
$125.00



Total

$0.00

Payment Methods

Debit or Credit Card

Choose from one of the PayPal options to make your payment.

Should be Empty:

Life Pacific University Wrestling Camp Registration