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Applications must be received by May 24, 2009. To enroll, complete and submit this form and enter your payment information for the full amount of camp tuition.
For further information call 205-652-3524. |
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Name
First, Middle, Last |
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Last 4 Digits of Social Security Number
Last 4 Digits of Social Security Number |
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Address
Street, City, State, Zip Code |
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Age |
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Birthdate
(mm/dd/yyyy) |
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Grade as of Fall 2009 |
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E-mail |
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Height |
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Weight |
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Position |
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School |
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School Location |
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Head Football Coach |
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Parents' Names |
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Parents' Home Phone
(xxx-xxx-xxx) |
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Parents' Business Phone
(xxx-xxx-xxxx) |
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Parents' E-mail Address |
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PARENTAL CONSENT AND WAIVER OF RESPONSIBILITY
It is agreed that all risks attendant to watching and/or participating in camp activities including, but not limited to bodily injury, are asssumed by the student and his parents and/or legal guardian and that this assumption is acknowledged, approved, and agreed to by said student and his parent's/guardians as indicated by their signature hereto. Sports Camp insurance will be financially responsible for injuries/accidents occurring during camp, only as secondary coverage after the parent's/guardian's insurance has paid. I hereby grant permission for physicians, dentists, other licensed providers and their designess to administer outpatient medical, surgical, or dental services as appropriate, or necessary antigens or other injections, to perform emergency procedures as necessary to refer to duly licensed medical personnel when indicated. |
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Parent or Legal Guardian |
Parent
Legal Guardian
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Date |
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Medical Clearance
I hereby certify the named camper is physically able to participate in West Alabama Sports Camps and I know of no physical impairments which would in any manner limit his participation in such program. |
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Physicians Name |
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Date |
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Medical Information |
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Hospitalization Plan:Claim No. |
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Company |
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City |
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State |
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Zip Code |
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Phone
(xxx-xxx-xxx) |
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Medical History (if pertinent): |
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Allergies, present medications, special considerations |
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Parent/Guardian |
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Address |
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City |
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State |
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Zip Code |
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Emergency Medical Contacts |
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Name |
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Home Phone
(xxx-xxx-xxx) |
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Name |
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Work Phone
(xxx-xxx-xxx) |
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Please mail a copy of your insurance card to the appropriate contact |
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