SPRING 2019 VOLLEYBALL CLINIC

FRANCIS CORNEJO VOLLEYBALL CAMP REGISTRATION FORM SPRING 2019
Participant Information
Participant's Name *

First Name Last Name

Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Phone Number *

- Area Code Phone Number
Student E-mail *
Birth Date *

Month Day Year
Age *
School *
Grade *
T-shirt size
Volleyball Experience (please check all that apply) *

Beginner (played 1 yr. or less) Advance Club High School
Position(s) Played (check all that apply) *

Left side hitter Right side hitter Middle hitter Libero/Defensive specialist Setter
Parent/Guardian #1
Parent/Guardian Name *

First Name Last Name
Parent E-mail *
Home Number

- Area Code Phone Number
Cell Number *

- Area Code Phone Number
Work Number *

- Area Code Phone Number

Medical Information
In case of emergency, please notify: *
Relationship to camper *
Emergency contact phone *

- Area Code Phone Number
Insurance Company Name *

Insurance Company Address *

Street Address
Street Address Line 2
City	State / Province
Postal / Zip Code	Country

Group # *
Policy # *

SPRING 2019 VOLLEYBALL Sessions
Payment Method

I will pay online I will pay by check
Please make checks out to: Francis Cornejo

Send printed form and check to:

Francis Cornejo

807 POINTER RIDGE DRIVE, GAITHERSBURG, MD 20878

Early registration discount applies if post marked before MARCH 1 2018. Deduct $25.00 off. This only applies to PAY BY CHECK selection.
Pay by check - please select camp session you wish to attend

BEGINNERS: Sat MARCH 16 - MAY 18, 2018 9AM - 11AM NCC $485.00 ADVANCE: Sat MARCH 16- MAY 18, 2018 11AM - 1PM NCC $485.00

Online Payment

Beginners: Saturday Mar.16- MAY 18, 2019 9AM-11AM NCC $ 485.00

Advance All Skills Sat Mar 16 - MAY 18, 2019 11 :00AM-1: PM NCC $ 485.00

Enter coupon

My child has my permission to participate in the Francis Cornejo Volleyball (The Camp). My child is in good health and able to participate in all normal volleyball camp activities.

Note: While your child is in the care of a coach, an emergency illness or accident may occur which requires immediate medical or dental attention. Your authorized consent, as the child’s parent or guardian, in advance of such treatment serves to protect you, the Camp, the volleyball coach, the doctor, and yourself by assuring that prompt emergency treatment can be administered. This form enables you to provide this consent as well as to offer information helpful in the treatment of your child.

The undersigned, parent(s) or guardian of the child named above, a minor, hereby authorize the coach, or such substitute as he or she may designate as agent for the undersigned, to consent to any X-ray examination, anesthetic, medical or surgical diagnosis or treatment and hospital care to be rendered to said minor under the general or special supervision and upon the advice of any physician or surgeon licensed under the laws of Maryland, and to consent to any X-ray examination, anesthetic, dental or surgical diagnosis or treatment and hospital care to be rendered to said minor by a dentist licensed under the laws of Maryland, whether such diagnosis or treatment is rendered at the office of said physician or dentist, in the hospital or otherwise. This authorization is given prior to any diagnosis or treatment known to be required in order to enable said coach or agents to act effectively in an emergency situation where I cannot be contacted. Should said coach or agents exercise their authorized consent hereunder upon the advice of a licensed physician and surgeon or dentist, I knowingly and voluntarily exonerate and release said coach or agents of the Francis Cornejo Volleyball Camp from liability for this action.
There are no refunds or make-up classes for missed sessions due to weather conditions or health reasons.

There will be a $75.00 processing fee for any cancellation. No exception.

Student is considered registered once payment has been received.

I understand that there are risk and danger inherent in participating and / or receiving instruction to participate and or receive instruction in this sport or activity during the said Camp/Clinic. I must give up my rights to hold Francis Cornejo, its coaches, instructors and all event sites liable for any inquiry or damage, which I may suffer while participating and/or receiving instruction in this sport activity. Knowing this and in consideration of being permitted to participate and/or receive instructions in this sport or activity, I hereby voluntarily release Francis Cornejo, its coaches and instructions and all even sites from an and all liability resulting from or arising out of my participating and or receiving instruction in volleyball, and hereby personally assume all risk in connection with participating and / or receive instructions in camp/clinic; where foreseen or unforeseen; and all event sites from any claim by me or my family, estate heirs or assigns, arising out of my participating and/or receiving instructions I this camp/clinic.

I understand and agree that I am releasing not only the entities set forth in the paragraph above, but also the officers, agents and employees of those entities.

I understand and agree that this Agreement applies to personal injury, property damage or wrongful death, which I may suffer, even if caused by the act or omission of others. I consent to Francis Cornejo’s Volleyball Camp the use of photograph and videotapes made of volleyball lessons for advertising their volleyball program.

By signing my name below (typing legal name) I understand that all reasonable measures will be taken to safeguard the health and safety of my child and that I will be notified as soon as possible in case of an emergency. I ACKNOWLEDGE THAT I HAVE READ THIS AGREEMENT AND THAT I UNDERSTAND THE WORDS AND LANGUAGE IN IT. I HAVE BEEN ADVISED OF THE POTENTIAL DANGERS INCIDENTAL TO PARTICPATE AND/OR RECEIVE INSTRUCTION IN SAID SPORT OR ACTIVITY. THIS AGREEMENT SHALL BE CONTRUED UNDER AND IN ACCORDANCE WITH THE LAWS OF THE STATE OF MARYLAND.
Parent E-Signature *
Should be Empty:

FRANCIS CORNEJO VOLLEYBALL CAMP REGISTRATION FORM SPRING 2019

Participant Information

Parent/Guardian #1

Medical Information

SPRING 2019 VOLLEYBALL Sessions