Name:____________________________________________________Age at Camp:_______________

Parent/Guardian Name:____________________________________Daytime Phone:________________

Address:______________________________________________________Phone:________________

City:________________________State:_______Zip:__________Emergency Phone:________________

Birthdate:_______________Height:________Weight:________

TRIPLE THREAT INC,
AUTHORIZATION FOR TREATMENT AND RELEASE OF LIABILITY

Please make record that in case of our unavailability, we ask that you care for our minor child should the medical need arise. You are authorized to perform or arrange for whatever treatment necessary in our absence. I hereby release, exonerate and discharge the camp, and its employees from any and all actions, known or unknown, for any injuries incurred while at camp or on the way to or from camp.

Parent/Guardian Signature:____________________________________________________

Player Signature:____________________________________________________________

Insurance Company:__________________________________________________________

Policy #:___________________________________________________________________