Athletic Program for Grades 3-4 (2010)

St. John the Evangelist Catholic School

Sports Camp Registration/ Parent Permission Form/Medical Release

Attention to all 3^rd and 4^th Grade Boys and Girls: Our Intramural Volleyball and Basketball Camp will take place on March 15^th and 17th at Canton Middle School from 6:30 p.m. until 8:20 p.m. The two session camp is intended to familiarize our younger students with each sport. Each evening will be comprised of a 50 minute volleyball session, a 10 minute snack break, and then a 50 minute basketball session. Each session will be led by coaches, sports committee members, and possibly some of our past players. Please bring a water bottle and a healthy snack. You do not have to attend both in order to participate. For more information please call Esteban Rodriguez at 630-736-1583.

The cost of the program this year will be $10 per student. Please submit this form, along with the money, to school by Friday March 12^th to Mark LaRue’s attention.

Participant’s Name:___________________________Grade:_________________

Address:_________________________________________________________

Parents Names:____________________________________________________

Home Phone: __________________

Mom’s Cell:______________________ Dad’s Cell:______________________

Family Physician:____________________________ Phone:_______________

PERSON TO CALL IN EMERGENY IF PARENTS CANNOT BE REACHED:

Name:________________________________ Phone:__________________

Relation to Participant:___________________________________________

Known Medical Problems or Allergies:______________________________

I, the undersigned, do hereby grant permission to the bearer of this note, to authorize emergency medical treatment for my son/daughter in the event that the persons listed above cannot be reached. I release from all responsibility all duly authorized officials, coaches, and representatives of the St. John’s Sports Program in the event of accidental injury or death.

Parent/Gurardian Signature:_________________________________________________

Registrants and participants permit the taking of photos and video of themselves and their children during program events for publication and use, and agree to permit the release of their names for photographs and stories for publication as the school deems appropriate.

Parent/Guardian Signature:_______________________________________________________