South End Sports Camp Registration

South End Summer Camp Registration
Are you a member?*

YesNo
Membership ID # (Number on back of your check-in card)*

Parent/Guardian Information
Name*

First NameLast Name
Cell Number*
E-mail*
example@example.com
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Emergency Information
Emergency Contact's Name*

First NameLast Name
Relationship*
Phone Number*
Permissions

I hereby grant permission for my child to be included in evaluations and pictures connected to the South End Club.

I hereby grant permission for my child to use all of the play equipment and participate in all of the activities of the JAWS program. I hereby grant permission for my child to be included in evaluations and pictures connected to the JAWS program and the South End Club.

The undersigned, as the parent(s), or legal guardian(s), of the above-named person, (the “minor”) hereby authorize the South End Club and its employees, and directors to consent to any x-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital care (collectively “medical care”) to be rendered to the minor under the general or special supervision and upon the advice of a physician or surgeon licensed under the laws of the state or other jurisdiction in which medical care is sought, and to consent to any x-ray, anesthetic, dental or surgical diagnosis or treatment and hospital care (collectively “dental care”) to be rendered to the minor by a dentist licensed under the laws of the state or other jurisdiction in which dental care is sought.

The undersigned understand and agree that South End Racquet and Health Club shall not be legally or financially liable for any bill or medical expense incurred, or for any cause of action or claim arising from any medical care or dental care provided, or the lack of medical care or dental care. The undersigned hereby agree to indemnify, defend, and hold the South End Club harmless from any claim made by or on behalf of the minor person or the minor’s heirs or parents or guardians arising out of any medical care or dental care provided.

*South End Club reserves the right to deny any entrance and / or continuation of camp to any child who is unruly and / or does not respect the rules of South End Club and the JAWS program.

NO CANCELLATIONS OR REFUNDS
By checking this field:*

I have read/completed and agree to all the above.
Medical Release and Authorization

If my child is injury in an accident or becomes seriously ill, and I or my designee cannot be reached, I authorize the director of summer programs to arrange for the transportation of my child to a licensed emergency medical care facility to receive prompt treatment. Furthermore, I authorize the medical personnel at the facility to provide such treatment to my child as is indicated by the nature and extent of his or her injury and that is in accordance with the protocols of standard medical practice. Finally, I accept full financial responsibility, for all costs, charges, and fees associated with the transportation of my child and for the treatment provided by the medical care facility to my child and absolutely and unconditionally agree to indemnify and to hold South End Racquet and Health Club Sports Camp harmless from all such costs, charges, and fees.
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.
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South End Summer Camp Registration

Child Information