Camp Registration

2010 Dynamic Solutions Speed and Athletic

Development Camp Application Form

Last Name: ____________________________ First Name: ______________________

Age: ____________________________ Date of Birth: __________________________

Street Address: __________________________________________________________

City/State/Zip: __________________________________________________________

Male/Female: __________

T-Shirt Size: Circle one: Adult: S M L XL Youth: S M L

Sports You Participate In: ___________________________

Home Telephone: ____________________________

E-mail address: ____________________________

Father’s Name: _________________________Mother’s Name:__________________

Work Telephone Numbers: Father ________________Mother:___________________

Personal Insurance Company: _____________________________________________

Policy #: ______________________________________________________________

WAIVER OF LIABILITY

In consideration of my participation in any strength and athletic training program for

sport I acknowledge that I understand the nature of the activity and that I, and/or my

minor child, am qualified, in good health and in proper physical condition to participate

in such activities. I fully understand this type of training involves a risk of serious bodily

injury, including permanent disability, paralysis, and death and these and other risks may

be caused by my own actions, or inaction. I, hereby release, discharge and covenant not

to sue Dynamic Solutions, their respective administrators, directors, agents, officers,

volunteers, and employees and any sponsors and advertisers of any Dynamic Solutions

events of which I participate from all liability, claims, demands, losses, or

damages on my account caused or alleged to be caused in whole or in part by the

negligence of the releases. I \acknowledge that I have read this release, waiver of liability

and express assumption of risk agreement and fully understand it.

X___________________________________ Date: __________

MEMBER SIGNATURE

X_________________________________________________

SIGNATURE OF PARENT OR LEGAL GUARDIAN