Winter Beginning Camp Form

Student Name________________________________________________

Address_____________________________________________________

City State Zip_________________________________________________

Telephone___________________________________________________

Email_______________________________________________________

Birth Date_______________ Age at Camp______ □ Male □ Female

Emergency Contact

Name_______________________________________________________

Phone_______________________________________________________

Relationship to Camper_________________________________________

Please indicate which Session(s) and package you would like to attend.

Required (Chose one)

□ Full Day Camp ($110)

□ Morning Camp($60)

□ Afternoon Camp ($60)

Optional (Chose one)

□ Morning Child Care ($20)

□ Afternoon Child Care ($20)

□ Both Child Care ($35)

□ Full day Family Or Additional 15% discount ($93.50)

□ Half day Family Or Additional 15% discount ($51.00)

Sub Total: _____________________

□ December Session (Tuesday, December 27-Friday, December 30)

Registration Fee: ___$10.00_________

Total: ________________________ check #_________________

A check must accompany each application. Make all checks payable to: Birmingham Fencing Club.

Send completed application and check to:

Birmingham Fencing Club

1425 Montgomery Highway 31 Suite 25

Birmingham, AL 35216

Allergic Reactions □ Yes □ No

If yes, list________________________________________________

Taking medications □Yes □ No

If yes, list________________________________________________

Personal Physician________________________________________

Telephone_______________________________________________

Preferred Hospital in Birmingham_____________________________

Emergency Phone Numbers_________________________________

Father work___________________________ Cell________________

Mother work___________________________ Cell________________

In an emergency if parents cannot be reached notify

Name___________________________________________________

Phone___________________________________________________

By participating in any class or activity sponsored by the Birmingham Fencing Club (the Club), I agree to abide by the rules of the Club. I give my consent to the Club and its representatives to provide first aid to the above named athlete (or any family member or guest of the athlete), and to obtain medical care for any such person (including first aid, medicines, anesthetics, surgery and prescription drugs) from any medical professional, for any injury or illness of any such person that may arise during activities associated with Club events. The Club and its officers, agents and employees shall not be liable for any first aid or other medical procedures provided pursuant to this consent. I agree that I am financially responsible for all expenses that may be incurred pursuant to this consent.

I understand that fencing, like all sports, involves a risk of injury (including serious injury, disability or death) to participants and spectators. I hereby waive and release any and all claims that I may have, on my behalf or on the behalf of others, against the Club, its landlord, directors, officers, coaches, managers, employees, agents and members, the United States Fencing Association, and any other participants in Club activities, from any and all costs, expenses and liabilities associated with any injury, illness or damage that arises from participation in any Club activity. I also grant the Club permission to use any photographs, videotapes or other recordings of Club classes or activities for any purpose that the Club deems appropriate.

_____________________________________________________________________________________________

Camper Signature Date

______________________________________________________________________

Parent or Guardian Signature (Required) Date