Alleman High School - Athletics - Sports Camps - Registration Form
Athletics: Sports Camps: Registration Form:
 

ALLEMAN HIGH SCHOOL -- 2008 SUMMER SPORT CAMPS

REGISTRATION FORM
   Camper's Name  ______________________________    School ____________________
   Registration for: ____ Boys Basketball - $35/$15 ____ Girls Basketball - $65/$25
____ Football - $50/$25 ____ Girls Soccer - $30/$15
____ Jr. Pioneer Football - $25/$15 ____ Cheerleading - $30/$15
____ Baseball - $30/$15 ____ Cross Country $40/$20
____ Boys Soccer - $50/$35 ____ Volleyball - $50/$25
                            ____ Band - $30/$15 (no T-Shirt)       ____ Grade School Volleyball - $35/$25
.
NOTE: The 2nd child rate applies only if it is for the same camp.   TOTAL AMOUNT $__________
Grade entering school year 2008-09 ________________________ Age _________________
Parent/Guardian Name ________________________________________________________
Address _______________________________ City/State/Zip _________________________
Home Phone _______________ Work Phone ______________ Cell Phone ______________
   T-Shirt Size: (Please Circle One)       Youth Medium         Youth Large          Adult Small           

                        Adult Medium          Adult Large       Adult X-Large            Adult XX-Large
As parent and/or legal guardian, I remain legally responsible for any personal actions taken by the above named minor ("Participant").
I understand the risk this activity presents to my child, including, but not limited to , serious personal injury or death. Any questions I have concerning this activity have been answered.
In consideration of my child being allowed to participate in this activity, I hereby RELEASE AND AGREE TO INDEMNIFY AND HOLD HARMLESS the Diocese of Peoria, the parish, the school, coaches, chaperones, volunteers or representatives associated with this event, and their employees and agents, from any and all liability for injuries, damages, medical expenses, or any other loss to my child or family or me (including attorney's fees) arising from or related to my child's participation in this activity.
___________________________________________                       _____________________
                 Parent/Guardian Signature                                                         Date

Make Checks payable to:

  Alleman High School

Send registration form and check to: 

 Steve Smithers, Athletic Director
 Alleman High School
 1103 40th Street
          (any questions or concerns phone 786-7793)  Rock Island, Illinois 61201
 

DEADLINE FOR REGISTRATION IN FRIDAY, MAY 16, 2008

 

MEDICAL INFORMATION
Student/Minor
   Name (First, Middle, Last): ___________________________________________________
   Address: __________________________________________________________________
 
Emergency Contacts
   Parent(s) or Guardian
   Name (First, Middle, Last): ___________________________________________________
   Phone (including area code): __________________________________________________
   Other Contact
   Name (First, Middle, Last): ___________________________________________________
   Relationship (friend, relative, neighbor, etc.): _____________________________________
   Phone (including area code): __________________________________________________
 
Student/Minor's Regular Physician
   Name (First, Middle, Last): ___________________________________________________
   Phone (including area code): __________________________________________________
 
Medical Conditions
   Please list any medical conditions of the above student/minor (asthma, diabetes, epilepsy, etc.):
   ________________________________________________________________________________
   ________________________________________________________________________________
 
   Please list any allergies or allergic reactions to medications of the above student/minor:
   ________________________________________________________________________________
   ________________________________________________________________________________
 
   Please list any medications the above student/minor is now taking:
   ________________________________________________________________________________
   ________________________________________________________________________________
 
   Date of student/minor's most recent tetanus shot: ________________________________
  
   Other pertinent medical information:
   ________________________________________________________________________________
   ________________________________________________________________________________
Medical Insurance Information
   Company: _________________________________________________________________
   Identification number of plan: __________________________________________________
   Identification number of covered employee: ______________________________________



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Last modified: Thursday, 19-Jun-2008 09:51:30 CDT