2008 Jerry Rhome Football Camp

Name:_________________________

Address:________________________

City:____________St:___ Zip:_______

Home #:_______________Cell:___________

School:____________________

Position(s):__________________ 

Grade:____________________

Age:____Date of birth: ______

Ht:___________ Wt:___________

T-shirt Size:   Youth   Youth      Adult                     Adult         

Circle one            S   M    L    XL         S   M   L   XL   XXL  

Parent/Guardian

Name:______________________________________

Phone:______________________________________

Medical Information

List medication player is taking:

_______________________________________

List all medical conditions currently treated:

________________________________________

Is player allergic to any medication?____Yes____No

List:_________________________

Date of Last Tetanus Shot: _________________

Insurance Company: _________________________

Policy #: ___________________

Parent/Guardian Release of Liability:

I/We, the undersigned, hereby certify that I am the parent or legal guardian of the player. I hereby give permission for the staff of the camp to seek medical attention for the player if it is deemed necessary during the camp. I will be responsible for any and all costs of medical attention and treatment. I/We, the undersigned, for ourselves, our heirs, our executors and administrators, waive, release and forever discharge Reinhardt College, Jerry Rhome Football Skills Camp, its staff, agents, employees and administrators from any liability due to personal injury, death or loss.

Parent / Guardian

Signature_____________________________________________

Date:_______________________________________________