Child's Name:   Age:   

Gender: Select One Female Male               DOB:

Address:

City:   State:   Zip Code:

Parent's Name:

Home Phone:     Cell Phone:

Email address:

Current School:  

Emergency Contact Name:

Phone 1:      Phone 2:

Medical/History:

Camp Session: Select On Session 1: July 20 - July 24, 2009

T-Shirt Type: Select One Youth Adult      T-Shirt Size: Select One Small Medium Large Extra Large 2X    

Extended Care (Please Select if applicable): If neccessary Extended Care

In case of an emergency, I understand that every effort will be made to contact me. In the event that I cannot be reached, I hereby give my permission to L.A.B. Sports to secure proper care. It is understood that I, as a parent/legal guardian will accept financial responsibility for payment of any emergency transport, care, physician, and any hospital expenses that might be required. I agree to indemnify, hold harmless and defend L.A.B. Sports, Alana Beard, Alana Beard Future, and the Alana Beard Foundation its officers, agents, servants and employees from any and all claims resulting from injuries, damages, losses or death sustained by me or my children and arising out of, connecting with, or any way associated with the activities of this program. Further, I give my permission for the Department to use, without limitation or obligation, photographs, film footage or tape recording which may include my/my child’s image.

Parent/Guardian Name: