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2014 Seneca Wallace Football Skillz Camp

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Page 1: 2014 Seneca Wallace Football Skillz Camp

Seneca Wallace Football Skillz Camp June 21, 2014

Prairie Ridge Sports Complex – Ankeny, Iowa PARTICIPANT INFORMATION PARENT/GUARDIAN INFORMATION Name___________________________ Name__________________________________ Birth Date________________________ Email__________________________________ Address__________________________ Cell Phone______________________________ City________________ Zip__________ Emergency Contact_______________________ Home Phone______________________ Emergency Contact Phone_________________ T-Shirt Size Youth sizes: ☐YS ☐YM ☐YL Health Insurance Co.____________________ (check one): Adult sizes: ☐S ☐M ☐L ☐XL Policy #________________________________ Age Group: ☐ 7yrs–12yrs (8 am – 12 pm) ☐ 13yrs–18yrs (12:30 pm – 4:30 pm) Player Position____________________

INSURANCE WAIVER I will take full responsibility for all uncovered medical expenses incurred by the participant during camp.

___________________________

Signature of Parent/Guardian PAYMENT INFORMATION Please make checks payable to: Joyce’s Angels Cost per participant: $20.00 Mail to: Joyce’s Angels C/O Monica Kim-Nguyen Check # ___________ Amount $_________ 1901 Avenue of the Stars, Ste 200

Los Angeles, CA 90067

PARENT/GUARDIAN SIGNATURE REQUIRED Informed Consent Release and Waiver of Liability and Indemnity Agreement: In consideration of being permitted to participate in any way in the Seneca Wallace Summer Football Camp, the parent(s) and/or legal guardian(s) of the minor participant named below agree: I am fully aware and thoroughly informed of the hazards of participating in a football camp; further, I have read and fully understand the following: That participation is voluntary and at my/minor’s own risk; That a Football Camp is a physical activity involving heavy exertion. A camp participant must be in good general health, free from cardiovascular and respiratory disease, or other disease or ailments and have good exercise tolerance; That while participating in a Football Camp the human body is subject to a variety of influences that may become potentially hazardous. Some of these hazards include, but are not limited to, severe head injury and a variety of other bodily injuries such as broken bones, including the potential for permanent disability and/or death; Notwithstanding these risks, for and in consideration of the minor’s participation, I, for myself, the minor and the minor’s assigns, heirs, executors, and successors do assume all responsibility for any and all risk of property damage or bodily injury and waive, release, discharge and hold harmless Joyce’s Angels and its directors, officers, members, employees, agents, affiliates, and volunteers (“Joyce’s Angels”), as well as those of the Prairie Ridge Sports Complex and its officers, employees, agents, volunteers and affiliates (“Prairie Ridge”) from any and all claims, demands, actions, causes of actions, costs and expenses for and by reason of any personal injury, property damage, loss and expense, which heretofore have been or hereafter may be sustained or suffered by the minor in consequence of and as a result of a certain accident, casualty or event or the minor’s presence or activities in connection with this football camp. I also agree to indemnify and hold harmless Joyce’s Angels and Prairie Ridge for injuries sustained either by the minor and/or caused by the minor to others during the football camp. Furthermore, I acknowledge that the risks outlined above are not intended to be all-inclusive and voluntarily accept all risks known or unknown. The participant of this football camp currently has no known mental or physical condition that would impair his/her capability for full participation as intended or expected of participant. The undersigned has carefully read the foregoing release and indemnification and understand the contents thereof and sign this release as its own, free act. ________ ________________________________________________________________________________ Date Print Parent/Guardian’s Name Signature of Parent/Guardian ________ _________________________________________________________________________________ Date Print Parent/Guardian’s Name Signature of Parent/Guardian

Contact us with any questions by email: [email protected] or call us at 213-290-5844