CHRISTIAN ACADEMY

Patriots Athletics & Activities Department

3400 Moanalua Road, Honolulu, Hawaii 96819 (808) 836-0233; Fax (808) 836-4415

Summer Volleyball League

Who: Boys & Girls entering Grades 4 - 8
When: Jun 13 – Jul 27, 2017 Tue & Thurs
5:00 pm – 6:30 pm
Where: The Dome, Christian Academy
Fee: $100 Payable to: Christian Academy
All applications are accepted unless otherwise notified. Receipt provided upon request.
For further information, please call Tracy Pagud @ (808) 836-4446 or
email

DETACH HERE

REGISTRATION FORM

Name ______Age ______Grade entering SY17-18 ______

Parent / Guardian Cell ______Email ______

Sports participated recently: ______

Medical Insurance Carrier ______Policy Number ______

Any Medical Problems, please specify ______

IN CASE OF EMERGENCY: 1st Contact/Phone ______2nd Contact/Phone ______

Physician Name/Phone ______

ASSUMPTION OF RISK AND RELEASE: I/We the undersigned, certify that the above child is in good physical health and able to participate in all activities of the Christian Academy Patriots Summer Basketball Clinic (CAPSBC). I/We also understand and acknowledge that there are inherent dangers and risks involved with participation in the above named program with Christian Academy. I/We understand that I/We should be covered during June 1 – August 1 by a private medical and liability policy; and I/We further understand that Christian Academy does not provide such insurance, or otherwise indemnify the individuals with respect to injuries or other liabilities arising out of participation of the CAPSBC. Therefore, in consideration of my/our child being permitted to participate in the CAPSBC, I/We agree to assume all risks and responsibilities surrounding her participation in the CAPSBC. I/We have read and understand any and all written materials setting forth the requirements for participation in the above referenced activity, as well as those explained by the instructor(s), and I/we agree to strictly observe them. Further, I/we, do for myself/ourselves, my/our heirs, executors, and administrators hereby accept full responsibility for my/our participation and agree to indemnify, release and discharge Christian Academy, its officers, employees, agents, and assign from any and all claims arising from such participation in the CAPSBC or growing out of or caused by any acts or omissions of the above named child during her participation in the CAPSBC.

MEDICAL INFORMATION AND CONSENT FORM: I/We, the undersigned, consent to and authorize any medical professional and others working under their supervision to treat my/our child for any injury or illness arising from or related to my participation in the Christian Academy Patriots Summer Basketball Clinic. I/We further agree to pay any and all such medical expenses, cost and other charges and to release and discharge and hold harmless Christian Academy, its officers, employees, agents, and assign from and against any liability or any claims or demands arising from or connected with such medical treatment or care.

Parent/Guardian Name (print) ______Signature ______Date ______