Middleburg Volleyball Academy

Middleburg Volleyball Academy
Middleburg Volleyball Academy
Camp Waiver and Release
2015 Summer Camp
Name of Participant:
__________________________________
I (We) the parent’s of ________________________,
Address: __________________________
consent to have the M.V.A. Volleyball Camp coaches act
City: ____________________________
on our behalf should an emergency situation arise, and I
State: ________ Zip: ________
(we) grant them permission to authorize medical
Phone: __________
We will have a notary available at check-in
for your convenience. Please make sure
attention recommended by the physician or hospital.
I (We) accept full responsibility for expenses incurred in any
Emergency Phone:_________________
you have necessary identification with you.
Email: ____________________________
You must be present in order for the notary
illness. It is understood that this authorization is given
to notarize your form.
in advance or any specific authority and power to render
Grade level for this fall: _____________
School attending: ___________________
diagnoses or treatment of any accident, injury or
Medical Ins. Co: ____________________
care with the aforementioned physician, in the exercise
Policy #: __________________________
of his or her best judgment, may deem advisable. It is
Family Doctor: _____________________
understood that efforts shall be made to contact me (us)
Does the player have any physical limitations:
in rendering treatment to my (our) child, but that any
______yes _____ no
of the treatment will not be withheld if I (we) cannot
If so, what? ________________________
be reached. This authorization is valid for treatment
Please accept my application for:
of emergencies when I (we) am not available to give
CAMP DATES: JUNE 8th-10th
_____ Elementary Camp K-6 9:00-10:30 (30.00)
_____ 7-8 grade (70.00)
CAMP DATES: JUNE 12th-14th
th
_____9 grade (100.00)
_____ T-SHIRT SIZE
Waiver must be signed
Mail application, signed waiver form and check
to:
Middleburg Volleyball Academy
Att: Carrie Prewitt
4949 Kalmia St
Elementary Camp $30.00
June 8-10, 2014
9:00-11:30
K-6 grade
Junior High Camp $70.00
June 8-10, 2014
Rising 7th and 8th graders
1:00-4:00
th
Incoming 9 Grader $100.00
June 11-13, 2014
9:00-11:30 and 1:00-4:00 (Thurs-Fri)
9:00-11:30 (Sat)
consent.
I (We) certify that my (our) child,
____________________________________,
is covered by a medical insurance policy and therefore, will
be covered in case of any injury incurred while participating
in this clinic.
_____________________________________
Signature of Parent(s)
Sworn and ascribed before me on this
____ day of _______________
in the year 20___
Middleburg, Fl 32068
(904)226-1033
Registration will cut off as soon as capacity is
reached. Only pre-registrations post marked by
May 21st will receive t-shirts.
____________________________________
Signature of Notary Public (affix stamp)