Little Pioneer Camp Little Pioneer Camp Registration Form 1 Registration2 Payment I am registering for:*Camp 1 - June 14-17Camp 2 - July 26-29Days attending:*All four days - $120I can only make a few days - $30 per dayI can attend these days:* Monday - $35 Tuesday - $35 Wednesday - $35 Thursday - $35 Total Price Price: $0.00 How did you learn about the camp?*CAMPER INFORMATIONPlease complete the following information about the camper you are registering.Name* First Last Date of Birth* Date Format: MM slash DD slash YYYY Age*Grade*High School Graduation Year*Height*Weight*T-Shirt Size*Youth XLSmallMediumLargeXLPARENT/GUARDIAN INFORMATIONPlease complete the following information about the parent/guardian of the camper you are registering.Name* First Last Email* Phone*Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code EMERGENCY CONTACT INFORMATIONWho should we contact in the event of an emergency?Name* First Last Phone*LIABILITY RELEASE AND WAIVER/ PARENTAL CONSENT FORM & MEDICAL RELEASE*I understand that MidAmerica Nazarene University is not sponsoring the JL Hoops Factory camp in which I am participating. I acknowledge and agree that participation is strictly voluntary and between the camp sponsor and myself. I further acknowledge and agree that while attending these camps and traveling to and from these camps there is the potential for accidents to occur. I for myself, my heirs, executors, administrator and anyone else who may claim on my behalf, covenant not to sue and WAIVE, RELEASE AND DISCHARGE MidAmerica Nazarene University, its officers, director, agents, employees, representatives and successors, for any and all claims or liability, whether foreseen or unforeseen, for personal injury or property damage directly or indirectly arising out of, or in the course of, my participation in the camp or league. I hereby certify that I am the parent or legal guardian of the camper. I hereby give permission to the staff of the Camp to seek during the period of the Camp appropriate medical attention for the camper and for medical attention to be given and for the camper to receive medical attention in the event of accident, injury, or illness. I will be responsible for any and all costs of medical attention and treatment, except for that covered by the camp’s limited secondary medical coverage policy. I for myself and as guardian of the camper understand that volleyball is an active, physical sport, and that injuries can take place during play. I understand that, as with any sport, injuries can occur, and we hereby acknowledge that our child is physically fit and mentally capable of participating in volleyball and camp activities. I represent that I have sought the opinion of our child’s pediatrician and he/she concurs that the camper is fully capable of safely engaging in these activities. I for myself, our heirs, executors and administrators, waive, release and forever discharge the JL Hoops Factory Camps and its staff, officers, agents, employees, representatives, successors and assign of and from all rights and claims for damages, injury, or loss to person or property which may be sustained or occur during participation in Camp activities or while at Camp, whether or not damages, injury, or loss is due to negligence. Do you accept the above terms? Total $0.00 Credit Card Card Details Cardholder Name CommentsThis field is for validation purposes and should be left unchanged.