2019 Elite Performance Football Camp Registration Form

Athlete Information

Athlete's Name

First NameLast Name

Position

Birth Date

MonthDayYear

Grade

Gender

T-Shirt Size (adult)

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry

How did you hear about our camp?

If Referred, who referred you?

Parent/Guardian Information

Name

First NameLast Name

Cell Number

Area CodePhone Number

E-mail

Phone Number

Area CodePhone Number

Emergency Information

Emergency Contact's Name

First NameLast Name

Relationship

Alt. Phone Number

Area CodePhone Number

Does the athlete have any allergies, chronic illness, or medical conditions? If yes, please describe. (if no please enter n/a)

Is the athlete prescribed an inhaler? If yes, please explain any instructions. (if no please enter n/a)

Informed Consent and Acknowledgement

I hereby give my approval for my child’s participation in any and all activities prepared by Elite Performance during the selected camp. In exchange for the acceptance of said child’s candidacy by Elite Performance, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Elite Performance 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 Elite Performance 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 basketball. Some of these injuries include, but are not limited to, the risk of fractures, paralysis, or death.

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 the Elite Performance 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.

Confirmation

BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT ALL INFORMATION ABOVE IS TRUE AND HAVE DISCLOSED ALL INFORMATION NECESSARY TO CARE FOR ABOVE ATHLETE. I HAVE ALSO READ AND UNDERSTAND THE CONSENT / MEDICAL RELEASE PORTION.

THIS DOCUMENT 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

***** Please note: Registration fees must be paid in full prior to 6/14/2019 for child to participate).

Registration is completed once this form has been received, and the fee has been paid in full.

Payment Options – Please pay prior to June 16th via PayPay to eliteperformancefootballcamp@outlook.com or you may send payment via cash or money order (no checks accepted this year please) to the address below:

Sean Flanagan

4206 Timothy Way

Crestwood, KY 40014

Once you click the submit button, you will get a confirmation email / and a Thank you message showing we have received it. If you do not get an email confirmation, we did not receive it. Please contact us directly if this happens. Again - registration is not complete until fee is paid in full prior to camp opening day.

Summer 2019 Football Camp Registration Form