Maverick Volleyball Camp Registration






1. First & Last Name

 

2. Age

 

3. Home Address

4. City

5. Select State

6. Zipcode

 

7. Parent’s Name

8. Parent’s Phone Number(include area code)

9. Parent’s Email Address

 

10. Church Name

11. Pastor’s Name

 

12. Grade in school

13. Position played

14. Years of experience

15. T-shirt size

 
16. Please read the following consent and release form:

Waiver and Release: I, the undersigned parent or guardian hereby consents to my child participating in the Maverick Volleyball Camp, an event sponsored by Providence Baptist College. If my child has medical conditions which may be relevant to a physician in the event of an emergency, I have listed them below. In the event an emergency occurs, I may be reached at the telephone number listed below. If I cannot be reached, I hereby authorize (type name below)

to make emergency medical decisions for my child. If there are any activities I do not want my child to be involved in, I have listed them below. I understand and hereby agree to assume all of the risks which may be encountered on said activity, including activities preliminary and subsequent thereto. I do hereby agree to hold Providence Baptist College and its agents and employees, harmless from any and all liability, actions, causes of actions, claims, expenses, and damages on account of injury to my child or property, even injury resulting in death, which I now have or which may arise in the future in connection with the activity or participation in any other associated activities. I understand I or my insurance company are responsible for covering all injuries which may occur. I expressly agree that this release, waiver, and indemnity agreement is intended to be broad and inclusive as permitted by the law of the state of Illinois and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. This release contains the entire agreement between the parties hereto and the terms of this release are contractual and not a mere recital. I further state that I have carefully read the foregoing release and know the contents thereof and I sign this release electronically as my own free act. This is a legally binding agreement which I have read and understand.
 

17. Parent or Guardian e-Signature

18. Limited Activities (if none, put “n/a”)

19. Emergency Phone Number(no spaces or characters, e.g. – 8479317222)

20. Secondary Number(include area code)

 

I have read the terms and conditions.

 

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Payment can be made by calling Mrs. Carrie Merriott at (847) 931-7222 x2065, or by mailing in payment to:
 
Providence Baptist College
345 W. River Rd
Elgin, IL 60123
 
 
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