The University of Akron High School Camp/Clinic Registation / Waiver Form Registration Form Name_______________________________ Age_________ Current Grade___________ Parent/ Guardian______________________ Address_____________________________ City___________ State______ Zip________ Home Phone__________________________ Work Phone__________________________ Emergency Contact_____________________ Emergency Contact Phone________________ Clinic Attending Dec. 27-29 Christams Break Pole Vault_______ Tuesday Night Workout Series_____________ Jan 17 MLK Day Clinic ___________________ March 12 Big Throw_____________________ Events & Personal Records ____________________________________ ____________________________________ ____________________________________ ____________________________________ Medical Information Camper Name______________________________ Allergic Reactions____________________________ Medication currently taking_____________________ _________________________________________ Circle if known to have any of the following conditions: Diabetes Epilepsy Hemophilia Heart Condition Past illness or other information that would be useful in the event that treatment is necessary: ___________________________________________________________________ ___________________________________________________________________ Emergency Medical Authorization I am aware of the risks, hazards and inherent dangers that may arise due to my child's participation in the University of Akron Track & Field Clinic being held at The University of Akron. (collecively referred to as the "UNIVERSITY"). In consideration for being allowed to participate in said activity, I herby release, waive and discharge UNIVERSITY, its instructors, agents, and employees from every claim, liability or demand of any kind sustained, wheteher caused by negilgence of the UNIVERSITY or otherwise. Thisrelease shall be binding upon any heirs, administrators,executors and assigns of mine. I further agree to indemnify the UNIVERSITY from any loss, liability, damage, or cost they mayincur dur to my participation in said activity in any way whether caused by the UNIVERSITY or otherwise. In the event of illness or injury resulting or arising directly or indirectly out of said activity, I herby give my my consent and authorzation for(1) the administration of emergency firat aid care and treatment at the scene of the emergency by faculty, staff memebrs or volunteers of the UNIVERSITY or (2) the adminstration of any treatment deemed necessary by a liscensed physician or dnetist and (3) the transfer to any hospital reasonably accessible. The authorization is not intended to cover major surgery unless the mediacl opinions of two(2) liscensed physicians or dentists, concurring in the necessity for such surgery, are obtained prior to the perfromnace of such surgery. I further declare and warrant that I am covered by sufficiant medical and edntal insurance and that such insurance will remain in effect durring my child's participation in said activity. ____________________________________________ _________________ Signature of Parent or Guardian Date
