Rimington Football Camp Online Registration


Camp Type:
Tuition:
Parent's Email Adress:
Campers Name
Camper's Age
Parent or Guardian's Name
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code	Health Insurance Information
Health Insurance Carrier
Policy Number
Carrier Telephone Number	DAVE RIMINGTON FOOTBALL CAMP WILL OFFER SECONDARY (EXCESS) COVERAGE TO CAMPERS
Has the participant had a physical exam in the past 12 months?	Yes No
Camp Uniform	T-shirt (Adult Sizes) S/M/L/XL/XXL

Participants Favorite Offensive Position	Line/QB/RB/TE/WR (pick one)
Favorite Defensive Position	Line/LB/OLB/DB (pick one)

PAYMENT METHOD

Credit Card (American Express, VISA, MasterCard and Discover Credit Cards Accepted).

If You are paying by Check/Money Order/Cashier Check. Please make the check payable to Boomer Esiason Foundation

Credit Card

Cardholder Name

Cardholders Telephone

Card Number

Expiration Date

(MM/YY)

Signature

CAMP DISCLAIMER MUST BE 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 AGREE TO ALLOW RIMINGTON FOOTBALL CAMP TO USE IMAGES OF MY CHILD FOR MARKETING PURPOSES FOR 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 ________________________________

EMERGENCY CONTACT INFORMATION

FIRST CHOICE

SECOND CHOICE