WAIVER RELEASE FORM
Big Man Camp Held: July 14-17, 2008
10:00 a.m. - 3:30 p.m.
Smyrna Recreation Community Center
200 Village Green Circle
Smyrna, Georgia 30080
Participants Name: ______________________________________ Emergency Contact: _______________________________________
Phone: (H) __________________________ (W) _____________________________ (Cell) _________________________________
Relationship to Participant: _________________________________________________________________________________________
PARTICIPANT INFORMATION: Please check the correct response and fill in any necessary information.
A. Is the participant allergic to anything?
YES ( ) NO ( ) If yes, please list ___________________________________________________________
B. Is the participant currently taking any medication?
YES ( ) NO ( ) If yes, please list ___________________________________________________________
C. Photo permission. Pictures may be taken at programs. We encourage parents to allow photos to avoid isolation of participants during photo sessions. Pictures are used for scrapbooks, Big Man Camp Website, publicity, or brochures. By signing this wavier you are also granting permission for photos to be taken.
EMERGENCY TREATMENT & TRANSPORTATION PERMISSION:
In case of accident or injury, Big Man Camp Staff & Coordinators have parental or guardian permission for emergency treatment and transportation. A signature below grants this permission.
Signature:___________________________________________________ Date:__________________________
INSURANCE INFORMATION: Health, medical, and hospital coverage is the responsibility of the participant, parent or guardian. PLEASE INCLUDE A COPY OF THE PARTICIPANTS MEDICAL/INSURANCE CARD.
Insurance Co: _________________________________________Policy#: _____________________________________________
HOLD HARMLESS-INDEMNITY RELEASE FOR PARTICIPANTS
SMYRNA RECREATION DEPARTMENT, THE CITY OF SMYRNA, BIG MAN CAMP STAFF & DAVID DUNN
CAMP WAVIER & RELEASE OF ALL CLAIMS:
Please read this form carefully and be aware that in signing up and participating in this program, you will be waiving and releasing all claims for injuries you might sustain arising out of this program. “As a participant in this camp, I recognize and acknowledge that there are certain risks of physical injury and I agree to assume the full risk of any injuries, damages or loss which I may sustain as a result of participating in any and all activities connected with or associated with The Big Man Basketball Camp. I agree to waive and relinquish all claims I may have as a result of participating in the program against The City of Smyrna, David Dunn, Big Man Basketball Camp Staff and its officers, agents, coaches, coordinators, servants and employees. I do hereby fully release and discharge The City of Smyrna, David Dunn, Big Man Basketball Camp Staff and its officers, agents, coaches, coordinators, servants and employees from any and all claims resulting from injuries, damages and losses sustained by me and arising out of, connected with or in anyway associated with the activities of this program.” I have read and fully understand the above Program Details and Waiver and Release all Claims.
Participant: ________________________________Please Print Name:________________________________Date: _______________
__________________________________________Please Print Name:________________________________Date: _______________
(Participant's Parent or Legal Guardian)