Please Provide the Following  Registration Information:

Each camper required have an individual form.

PLEASE NOTE: 

OFFENSIVE LINE CAMP REQUIRE HELMET AND SHOULDER PADS. 

PLEASE CHECK OUT EQUIPMENT FROM YOUR HIGH SCHOOL COACH FOR CAMP

Camp Type	CAMP INFORMATION Choose Camp Youth Football Camp (Ages 8-14) Offensive Line Camp (Grade 9-12)
Tuition	Camp Tuition Early Bird Internet Special $125 (before June 26) Youth Football Camp Tuition @ $150 per camper after 6/26 Offensive Line Camp Tuition @ $150 per camper after 6/26
	CAMPER AND PARENT/GUARDIAN INFORMATION

Campers Name
Camper's Age
Parent or Guardian's Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Health Insurance Carrier
Policy Number
Carrier Telephone Number	DAVE RIMINGTON FOOTBALL CAMP WILL OFFER SECONDARY (EXCESS) COVERAGE TO CAMPERS
Camp Uniform	T-shirt (Adult Sizes) S/M/L/XL/XXL
Has the participant had a physical exam in the past 12 months?	Yes  No
Participants Favorite Offensive Position	Line/QB/RB/TE/WR (pick one)
Favorite Defensive Position	Line/LB/OLB/DB (pick one)

	PAYMENT METHOD Credit Card (AMEX/VISA/MASTERCARD/DISCOVER CARD ACCEPTED) Register Online, Telephone, Mail  or by FAX when paying by Credit Card.  If You are paying by Check/Money Order/Cashier Check. Please make the check payable to Dave Rimington Football Camp and mail it to: Mail to: Rimington Football Camp 1004 Lincoln Road,  #118 Bellevue, NE  68005 Kelly Faiman - Director 402-977-3193 Message Center 402-490-7761 Mobile 402-291-4279 Fax
Credit Card	VISA MasterCard American Express Discover
Cardholder Name
Cardholders Telephone
Card Number
Expiration Date	(MM/YY)
	CAMP DISCLAIMER MUST BE CHECKED IF SUBMITTING ONLINE OR SIGNED BY LEGAL GUARDIAN IF SUBMITTING BY MAIL OR FAX.
PART I By Checking this box you agree to the terms and conditions of PART I of the Rimington Football Camp Disclaimer	I AM THE PARENT OR GUARDIAN OF THE NAMED CHILD WHO IS A CANDIDATE TO BE PARTICIPATE AT THE DAVE RIMINGTON YOUTH FOOTBALL CAMP.  I HEREBY GIVE MY APPROVAL TO THE PARTICIPATION IN ANY AND ALL OF THE ACTIVITIES OF THE CAMP 2001.  INCLUDED BUT NOT LIMITED TO PRACTICES, DRILLS, GAMES, TOURNAMENTS, WEIGHT TRAINING INSTRUCTION, IF ANY, AND ANY OTHER ACTIVITY ASSOCIATED WITH THE CAMP ON AND AFTER THE DATE HEREOF.  IN CONSIDERATION OF YOU PERMITTING MY CHILD TO PARTICIPATE IN THE CAMP AND THE ACTIVITIES, AND IN CONSIDERATION OF THE TIME AND EFFORT DEVOTED BY THE COACHES AND SUPERVISORS AND STAFF OF THE CAMP.  I ASSUME ALL RISKS AND HAZARDS TO INCIDENTAL TO THE CONDUCT OF THE ACTIVITIES AND TRANSPORTATION TO AND FROM THE ACTIVITIES.    SIGNED (PARENT OR LEGAL GUARDIAN)  _____________________________________________________________________  PLEASE TYPE NAME BELOW  THEN PRINT OUT THIS FORM AND SIGN IF MAILING OR FAXING REGISTRATION FORM. DATE ________________________________
Part II By Checking this box you agree to the terms and conditions of PART II of the Rimington Football Camp Disclaimer	I FURTHER HEREBY RELEASE, ABSOLVE, INDEMNIFY AND AGREE TO HOLD HARMLESS DAVE RIMINGTON, BOOMER ESIASON, BOOMER ESIASON FOUNDATION, BOOMER ESIASON FOUNDATION BOARD OF TRUSTEES, TONY FELICI, KELLY FAIMAN, THE ORGANIZERS, DIRECTORS, SPONSORS, SUPERVISORS, COACHES, REFEREES, COUNSELORS, THE FACULTY, AND ADMINISTRATION AND EACH OF THEM, FROM ANY CLAIM, DEMAND, OR ACTION ARISING OUT OF, OR IN ANY WAY RELATED TO THE RIMINGTON YOUTH FOOTBALL CAMP OR RELATED ACTIVITIES, INCLUDING BUT NOT LIMITED TO ANY INJURY TO MY CHILD EXCEPT AND ONLY TO THE EXTENT OF AND IN THE AMOUNT COVERED BY ANY ACCIDENT OR LIABILITY INSURANCE.  IN THE EVENT OF AN INJURY, THE RIMINGTON YOUTH FOOTBALL CAMP STAFF IS AUTHORIZED TO OBTAIN ANY MEDICAL CARE OR TREATMENT DEEMED NECESSARY.  I HAVE CAREFULLY READ THE ABOVE WAIVER AND RELEASE AND FULLY UNDERSTAND THIS IS A RELEASE OF LIABILITY AND I SIGN IT VOLUNTARILY.   SIGNED (PARENT OR LEGAL  GUARDIAN)_____________________________________________________________________   PLEASE TYPE NAME BELOW  THEN PRINT OUT THIS FORM AND SIGN IF MAILING OR FAXING REGISTRATION FORM. DATE ________________________________   HOME PHONE WORK PHONE CELL PHONE PAGER HOME PHONE WORK PHONE CELL PHONE PAGER EMERGENCY CONTACT INFORMATION FIRST CHOICE SECOND CHOICE