Severn Volleyball Camp Form

Severn Volleyball Camp

July 30th-31st 2024 | 5:00-7:00pm | Edward St. John Athletic Center | Severn School
Camper's name*

First NameLast Name
Camper's date of birth*

MonthDayYear
Date
Camper's address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian email address*
example@example.com
Current school*
Grade you'll be entering in fall 2024*
Emergency Contact Information
Contact #1 - name*

First NameLast Name
Contact #1 - phone number*
Please enter a valid phone number.
Contact #1 - email address*
example@example.com
Relationship to camper*
Contact #2 - name*

First NameLast Name
Contact #2 - phone number*
Please enter a valid phone number.
Contact #2 - email address*
example@example.com
Relationship to camper*
Medical Information
Physician's name*
Physician's phone number*
Please enter a valid phone number.
Is your child currently on medication? (ex: inhaler)*

YESNO
If YES, does the medication require any special consideration/attention?
Does your child have any known allergies?*

YESNO
If YES, please list all allergies.
Liability Form
The undersigned, being a parent or legal guardian of this camper, understands and accepts that injury is possible while participating in the sport of volleyball. I knowingly assume all risks associated with my child’s participation in starting a course of instruction in volleyball training (The Activity), even if arising from negligence of the participants or others, and assume FULL responsibility for my child’s participation.
In full consideration of the risk of injury while participating in the Activity, and for the right to participate in the Activity, I hereby, for myself, my heirs, executors, administrators, assigns, or personal representatives, knowingly and voluntarily participate in this waiver and release of liability and hereby waive any and all rights, claims or causes of action of any kind whatsoever arising out of my participation in the Activity, their affiliates, managers, members, agents, attorneys, staff, volunteers, heirs, representatives, predecessors, successors and assigns, for any kind of risks related to traveling to and from as well as participating the Activity, which may include, but are not limited to, physical or phycological injury, pain, suffering, illness disfigurement, temporary or permanent disability, economic or emotional loss, and death.
Additionally, I authorize the sport camp staff to secure the proper medical care as necessary to insure my child’s wellbeing. I hereby acknowledge that I am responsible for medical charges incurred during sports camp participation. I further understand that the sports camp carries an excess medical insurance policy for sports injuries to the camper that may result from camper activities. This policy may only be utilized after my primary insurance company has processed the claims and issued an explanation of benefits. I certify that within the past 12 months my child has had a physical exam by a physician or NP and that he/she is physically able to participate in the sports camp activities. I also give permission for the camp directors to take pictures of the camper to use for further promotions of Severn volleyball camps and clinics.
I acknowledge that I have carefully read this form and fully understand that it is a release of liability. I expressly agree to release and discharge the trainer or instructor from any and all claims or causes of action and I agree to voluntarily give up or waive any right that I may otherwise have to bring a legal action for personal injury or property damage.
Date*

MonthDayYear
Camper Name*
Parent/Guardian Name*
Camper/Parent/Guardian Signature (if camper is under 18 years of age, parent/guardian must sign)*

Clear
Payment
Payment can be made in the form of cash, check, Zelle - using phone number (407) 718-2337, or Venmo - using username ErinBernhardt. Checks can made payable to “Bernhardt Performance LLC.” Payment will be accepted up until the first day of camp!

Mail checks to: 3 Baldridge Rd., Annapolis, MD 21401
Should be Empty:

Severn Volleyball Camp

Emergency Contact Information

Medical Information

Liability Form

Payment