I
represent that my child is covered under a qualified
health and medical insurance plan. The undersigned
parent or legal guardian of
the participant(s),
does hereby represent that he/she is, in fact, acting in
such capacity and agrees to indemnify, defend,
and hold harmless each and all of the Releases from all
liability, loss, costs, claim or damage whatsoever.
Street Address
City
State
Zip
Home Phone
Emergency
Phone
Email
Participant Information
Camp
Participant
Camp Fee
Date of Birth
Month
Day
Year
Camp City/Date
Additional
Participant
Camp Fee
Date of Birth
Month
Day
Year
Camp City/Date
Total
Check payable to:
Rockers Soccer
17387 Francavilla Dr
Livionia, MI, 48152
Waiver and Release must be
signed and turned in with your registration! I understand and agree
the Rockers Summer Camp ("Program") in which I
am enrolling my child involves strenuous physical activities and
should be engaged in only by persons in good health. I
understand and agree that neither the Program nor instructors or
those arranging the Program are qualified to determine my child's
physical condition or health and that it is my responsibility
to consult a physician prior to my child's participation in
this program. I further understand and agree that my child may
decline to participate in any particular activity or exercise,
which he/she feels, is beyond his/her ability.
I hereby agree, for myself and my child and our respective
heirs, assigns and legal representatives, to indemnify, defend
and hold Rockers Soccer and its directors, board members,
employees, agents, independent contractors and other
participants in the Program ("Releases") harmless
from any and all claims and causes of action of any nature for
any and all personal injury or illness, including death, which
may occur to my child or hereafter have against Releases which
may at any time arise as a result of any act or thing occurring
in or arising out of my child's participation in the Program.
I further expressly understand and agree that the foregoing indemnify,
release and waiver is intended to be as broad and inclusive as
is permitted by the law of the State of Michigan and that any
portion thereof is held invalid, it is agreed that the balance
shall, notwithstanding, continue in full force and effect.
Rockers
Soccer