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Grade Level (required):—Please choose an option—Grades 3-6Grades 7-10

Player Name (required):

Contact Email (required):

School District (required):

Emergency Contact Number (required):

HEALTH & GENERAL HISTORY: If the player should be restricted from any activity please note:

Please identify any medical condition or medical history that would require special attention:

Release of Liability

As the parent (guardian) of the named player I give permission to receive emergency medical or surgical treatment and hospitalization if necessary. I understand that every attempt will be made to contact me, or the emergency contact named above, before taking this action. I will be financially responsible for any medical attention needed during camp or resulting from an injury received at camp. My medical insurance shall be the insurance coverage for any medical treatment. I further agree that my child can receive over-the-counter remedies if necessary. (Tylenol, Sudafed, etc.) Please give special instructions above if you do consent to your child receiving over-the-counter medications.

I HAVE READ THE POLICIES AND FULLY UNDERSTAND MY OBLIGATIONS STATED THEREIN AND ALSO THE RIGHTS
OF Ultimate Team Camps, AND HERBY AGREE TO ACT IN ACCORDANCE.

I also agree that my child may be transported by bus and/or camp vehicle to an off-site medical center or for emergency medical treatment. The undersigned further expressly agrees that the attached waiver and assumption of risks agreement is intended to be as broad and inclusive as is permitted by law and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect.

In consideration of my minor child/ward (“my child”) being allowed to participate in UTC Fire, its related events and activities, I, the undersigned, acknowledge, appreciate, and agree that:

1. The risk of serious injury from the sports activities involved in this program is always present due to the nature of the sport (s); and

2. FOR MYSELF, SPOUSE, AND CHILD, I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES or others, and assume full responsibility for my child’s participation; and

3. I willingly agree to comply with the program’s stated and customary terms and conditions for my child’s participation.

If, however, I observe any unusual significant concern in my child’s readiness for participation and/or in the program itself, I will remove my child from participation and bring such to the attention of the nearest official immediately; and

4. I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE,

INDEMNIFY, AND HOLD HARMLESS the Camp, Ultimate Team Camps, its affiliates, officers, officials, agents and/or employees, other participants, sponsoring agencies, sponsors, advertisers, and, if applicable, owners and lessors of premises used for activity (“Releases”), WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH, OR LOSS OR DAMAGE TO PERSON OR PROPERTY, regarding my child and/or arising from his/her activities, WHETHER ARISING FROM NEGLIGENCE OF THE RELEASEES OR OTHERWISE, except for willful misconduct, or otherwise to the fullest extent of the law. I HAVE READ THIS HEALTH FORM AND RELATED CERTIFICATIONS, THE RELASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND THEIR TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.

I am certifying I have legal ability to consent for the camper. I agree that all information provided is accurate to the best of your knowledge. I am over the age of 18 and I allow Ultimate Team Camps to act in the best determined interest of my child should there be contact not be possible or available. [/acceptance]

Parent/Guardian Signature (required):

Date (required):

Intended Payment Option (required):—Please choose an option—Venmo: @brad-duckworth-4Mail to: UTC, 1540 Brookhaven Way, Plover, WI 54467Credit Card (Please proceed below)