Name:
Address:
Phone:
Email:
Gender:
Age:
Club/Team :
Parent/Guardian Name:
Payment Type:	Mail CheckSubmit Electronically
Consent:
I hereby permit my child to participate in the Winter Indoor GK Training at Game On Sports, conducted by Ron Apollon and Dan Pietro. By the execution of this release, I acknowledge and agree that all requirements, directions, supervision, and standards set by the directors of this program Ron Apollon and Dan Pietro shall be established for his/her benefit. I hereby voluntarily assume all risk of accident or injury to my child which may arise out of his/her participation in this program, hereby intending to release all personnel associated with this program from liability that may result from his/her participation. In addition, I hereby give my permission for emergency medical treatment in the event I cannot be reached.
I consent to the terms above:	YesNo
Parent/Guardian Name:
Agreement Date:
Camper's Name:
Emergency Contact:
Emergency Phone #(s):
Relationship:
Insurance Carrier:
Policy Number:
Physician:
Physician Phone #:
Known Allergies: