Rockers Soccer 
Summer Camps 2011 Registration

 

Under Construction! Do not use yet!

 

Parent/Guardian Information and Waiver

Parent/Guardian

I represent that my child is covered under a qualified health and medical insurance plan. The undersigned parent or legal guardian of the participant(s), does hereby represent that he/she is, in fact, acting in such capacity and agrees to indemnify, defend, and hold harmless each and all of the Releases from all liability, loss, costs, claim or damage whatsoever.

Street Address
City
State
Zip
Home Phone
Emergency Phone
Email

Participant Information

Camp Participant Camp Fee 
Date of Birth Month  Day Year
Camp City/Date
Additional Participant Camp Fee
Date of Birth Month Day Year    
Camp City/Date Total

Check payable to:

Rockers Soccer
17387 Francavilla Dr
Livionia, MI, 48152

Waiver and Release must be signed and turned in with your registration!
I understand and agree the Rockers Summer Camp ("Program") in which I am enrolling my child involves strenuous physical activities and should be engaged in only by persons in good health. I understand and agree that neither the Program nor instructors or those arranging the Program are qualified to determine my child's physical condition or health and that it is my responsibility to consult a physician prior to my child's participation in this program. I further understand and agree that my child may decline to participate in any particular activity or exercise, which he/she feels, is beyond his/her ability. I hereby agree, for myself and my child and our respective heirs, assigns and legal representatives, to indemnify, defend and hold Rockers Soccer and its directors, board members, employees, agents, independent contractors and other participants in the Program ("Releases") harmless from any and all claims and causes of action of any nature for any and all personal injury or illness, including death, which may occur to my child or hereafter have against Releases which may at any time arise as a result of any act or thing occurring in or arising out of my child's participation in the Program. I further expressly understand and agree that the foregoing indemnify, release and waiver is intended to be as broad and inclusive as is permitted by the law of the State of Michigan and that any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full force and effect. 

Date:        Parent Signature

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