2013 husky football 7-on-7 passing camp

R E G I S T R AT I O N F O R M ( PA G E 1 O F 4 )
2013 HUSKY FOOTBALL 7-ON-7 PASSING CAMP REGISTRATION FORM
Friday, June 21st AND/OR Saturday, June 22nd
Each participating camper must have this form filled out completely and turned in to their coach
prior to arrival at camp.
PERSONAL INFO
1. Name: 2. Camp:
June 21st $20
June 22nd $20
3. School: 4. Grade you will enter in the Fall 2013: 5. Position(s):
Offense
Defense
Specialist
State: Zip Code: 6. E-Mail Address (VERY IMPORTANT): 7. Street Address: City: 8. Telephone Numbers (Include area code):
Daytime:
Evening:
9. T-Shirt Size: Adult (check one)
XXXL
XXL
XL
L
Cell:
M
S
PAYMENT METHOD
1. CASH
2. MONEY ORDER (Payable to: Husky Football Camps) Phone: (206) 616-1545
Fax: (206) 685-1835
NO PERSONAL CHECKS ACCEPTED
E-Mail: [email protected]
WA I V E R F O R M ( PA G E 2 O F 4 )
2013 HUSKY FOOTBALL 7-ON-7 PASSING CAMP
Waiver of Liability, Release, Assumption of Risk, Indemnity,
Hold Harmless Agreement, and Consent for Use of Photographs, Name, Likeness
Name of Attendee: Age Date of Birth
WAIVER OF LIABILITY AND RELEASE. In consideration for the Attendee being permitted to participate in the Husky Camp(s) activities as check-marked/designated in Attendee’s Application, I do
hereby, and on behalf of Attendee, Attendee’s heirs, personal representatives or assigns, waive and
release forever, any and all rights for claims and/or damages Attendee may have against the Husky
Football Camps, staff, employees, agents, and volunteers (collectively “Camp Staff”), and the University of Washington, its board, officers, agents, and employees (collectively “UW”), from and against
any and all liability for any harm, injury, damage, claims, demands, actions, costs, and expenses of
any nature, which Attendee may have or may hereafter accrue to Attendee, arising out of or related
to, including, but not limited to, Attendee’s participation in any of the Husky Football Camps 2013
(“Husky Camps”), including ANY loss, damage, or personal injury that may be sustained by Attendee
or by any property belonging to Attendee, whether caused by negligence or carelessness on the
part of any coach, Camp Staff, or UW, or otherwise, while Attendee is in, on, upon, or in transit to or
from the premises where the Activities or any adjunct Camp activities are being conducted. I do
hereby, and on behalf of Attendee, intend this to be a complete and unconditional release of all liability to the greatest extent allowed by law.
ASSUMPTION OF RISK. I do hereby, and on behalf of Attendee, accept, understand and assume that
participation in Husky Camps carries with it certain inherent risks that cannot be eliminated regardless of the care taken to avoid injuries. I do hereby, and on behalf of Attendee, accept, understand
and assume that Husky Camps carry with them inherent risks due to the physical nature of the activities which include, but are not limited to, physical contact with other participants, footballs being
thrown, physical drills, and activities related to playing a physical sport like football. I do hereby, and
on behalf of Attendee, accept, understand and assume that these risks include minor injuries such as
scratches, bruises, sprains, more serious injuries, including possible permanent physical and/or mental damage, heart attacks, concussions, and even paralysis or death. I do hereby, and on behalf of
Attendee, agree that Attendee has agreed to follow all instructions of coaches and Camp Staff, and to
wear all necessary, recommended, and appropriate protective gear and equipment during the course
of the Husky Camps.
INDEMNITY AND HOLD HARMLESS AGREEMENT. I do hereby, and on behalf of Attendee, agree to
indemnify and hold coaches, Camp Staff, and UW harmless from any and all claims, actions, suits,
procedures, costs, expenses, damages, liabilities, and any attorneys’ fees brought as a result of Attendee’s involvement in the Husky Camps, and I agree to reimburse the coaches, Camp Staff, and UW
for any such expenses incurred by them.
CONSENT FOR USE OF PHOTOGRAPHS, NAME, LIKENESS. I do hereby, and on behalf of Attendee,
authorize Husky Camps and UW, to take photographs and video recordings of Attendee and/or myself in connection with the Husky Camps. I agree that Husky Camps and UW shall own exclusively all
copyright and other rights to such photographs and video, and may use them, as well as my name and
Attendee’s name and likeness, forever and throughout the world, in any and all media, in connection
with promoting or publicizing Husky Camps, and current or future events, without compensation to
myself or Attendee.
Initials
WA I V E R F O R M ( PA G E 3 O F 4 )
2013 HUSKY FOOTBALL 7-ON-7 PASSING CAMP
Representation of Attendee’s Physical Fitness to Participate and Severability
REPRESENTATION OF ATTENDEE’S PHYSICAL FITNESS TO PARTICIPATE. I do hereby, and on behalf
of Attendee, represent that, within one year prior to the date of the execution of this form, Attendee has undergone a full and complete physical examination administered by a Board-certified physician who will supply, if requested to do so, to Husky Camps or UW or its designated representative,
a letter certifying, on the basis of this examination, that Attendee is physically fit to play the game
of football and otherwise to participate in the Husky Camps.
SEVERABILITY. I do hereby, and on behalf of Attendee, further expressly agree that the foregoing
“Waiver of Liability and Release, Assumption of Risk, and Indemnity and Hold Harmless Agreement” is intended to be as broad and inclusive as is permitted by law, and that if any portion thereof is held to be invalid, that it is agreed that the balance shall, notwithstanding, continue in full
legal force and effect.
Please place a checkmark below indicating if you are the parent or legal guardian of a minor Attendee
OR if you are an adult Attendee (18 years or older)
CERTIFICATION OF PARENT OR LEGAL GUARDIAN. I certify that I am the parent or legal guardian of the child Attendee listed above. I acknowledge I have carefully read the full contents of this
“Waiver of Liability, Release, Assumption of Risk, Indemnity and Hold Harmless Agreement,” that I
fully understand its contents, and have signed below on my behalf and also on behalf of Attendee,
of my own free will.
CERTIFICATION OF ADULT ATTENDEE. I certify that I am at the time of this signature over the
age of 18. I acknowledge I have carefully read the full contents of this “Waiver of Liability, Release,
Assumption of Risk, Indemnity and Hold Harmless Agreement,” that I fully understand its contents,
and have signed below of my own free will.
Signature of Adult Attendee OR Parent/Guardian on Behalf of Minor Attendee
Printed Name of Parent/Guardian of Minor Attendee
Date
Telephone
**ATTENTION**
Please ensure you have both (1) initialed page 1 of this Waiver, and (2) Signed and Dated this Waiver
above. Otherwise, your application process will be delayed.
M E D I C A L C O N S E N T / R E L E A S E F O R M ( PA G E 4 O F 4 )
2013 HUSKY FOOTBALL 7-ON-7 PASSING CAMP
Consent for Medical Treatment, Release Authorization for Emergency Treatment
and Attendee’s Proof of Medical Insurance
Name of Attendee: Age Date of Birth
CONSENT FOR MEDICAL TREATMENT. I do hereby, on my own behalf or on behalf of Attendee
if a minor, give consent to the University of Washington Husky Football Camps staff, employees,
agents, and volunteers (collectively “Camp Staff”), and the University of Washington, its agents, employees (collectively “UW”) to obtain medical treatment and assistance on my/Attendee’s behalf, if
such treatment should be necessary or desirable during the course of my/Attendee’s participation
in the Husky Football Camps 2013 (“Husky Camps”). I do hereby, and on behalf of myself/Attendee,
acknowledge, however, that I will be solely responsible for the cost of such treatment, or for any
other medical treatment, for myself/Attendee.
RELEASE AUTHORIZATION AND CONSENT FOR EMERGENCY TREATMENT, OPERATIVE PROCEDURES. In the case of an emergency and if I cannot be reached, I do hereby, on my own behalf or on
behalf of Attendee, authorize coaches, Camp Staff, and/or UW to obtain whatever medical treatment he/she deems necessary, including emergency treatment that includes, but is not limited to,
operative procedures, if necessary, for the welfare of myself/Attendee. I do hereby, and on behalf of
myself/Attendee, further understand that I will be financially responsible for all charges and fees incurred in the rendering of such treatment, regardless of whether or not my medical insurance would
cover such charges and fees.
PROOF OF MEDICAL INSURANCE FOR ATTENDEE. I do hereby, on my own behalf or on behalf of
Attendee, understand that I am required to maintain and carry accident medical insurance coverage
for myself/Attendee for the duration of the Husky Camps. By my signature below I am verifying and
warranting that I/Attendee does have such coverage.
EMERGENCY CONTACT INFORMATION. In the event of an emergency, please contact:
Name of Emergency Contact
Relationship to Attendee
Telephone (Daytime)Telephone (Evening)
CERTIFICATION OF PARENT OR LEGAL GUARDIAN. I certify that I am the parent or legal
guardian of the child Attendee listed above. I acknowledge I have carefully read the full contents of
the foregoing “Consent for Medical Treatment, Release Authorization for Emergency Treatment, and
Attendee’s Medical Insurance,” that I fully understand its contents, and have signed below, and also
on behalf of Attendee, of my own free will.
CERTIFICATION OF ADULT ATTENDEE. I certify that I am, at the time of this signature, over the
age of 18. I acknowledge I have carefully read the full contents of the foregoing “Consent for
Medical Treatment, Release Authorization for Emergency Treatment, and Attendee’s Medical Insurance,” that I fully understand its contents, and have signed below of my own free will.
Signature of Adult Attendee OR Parent/Guardian on Behalf of Minor Attendee
Printed Name of Parent/Guardian of Minor Attendee
Date
Telephone