Consent to Medical Treatment and Release of Liability

Camp Blaze

2017

Consent Form

Consent to medical treatment and Release of Liability

I hereby authorize my child to participate in the volleyball camp offered by Chy Thompson and Push 1 VBC. By the execution of this release, I acknowledge and agree that all directions, requirements, supervisions, and standards set by the director/coaches/sponsors of this program shall be established for my child’s benefit. I hereby voluntarily assume all risk of accident or injury to my child that may arise out of her participation in this program, and therefore release Coach Chy Thompson, the camp staff and sponsor, New Manchester of any responsibility and liability that may result in my child’s participation in this camp. In addition, I give my permission for emergency medical treatment in the event I cannot be reached in a timely manner.

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Parent/Guardian Signature Date

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Print Camper’s Name Registrant’s Initials

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Emergency Phone and Contact

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Insurance Carrier and policy number

Bring completed forms and fee to camp or mail to:

Camp Blaze 2017

c/o Chy Thompson

P.O. Box 1966

Lithia Springs GA, 30122