Emergency Contact Form - Summer School Sports

How many children are you registering

Your Childs Name

First

Last

Date of Birth

Your Childs Name 2

First

Last

Date of Birth 2

Your Childs Name 3

First

Last

Date of Birth 3

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Email

Phone

Primary Care Provider

Emergency Contact

Name

First

Last

Address (If Different than Childs Address)

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Home Phone

Work Phone

Cell Phone

Relationship to the patient

Agree for release of liability

please check if you agree to the following

The participant understands and acknowledges the inherent risks associated with the activity/event. The participant releases the organization and its representatives from any claims or liabilities arising from participation in the activity/event. The participant agrees to indemnify and hold the organization harmless from any claims brought against the organization as a result of their actions or negligence.

Signature

Clear Signature