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)