GOLDEN GATE SUMMER SHOOTOUT

REGISTRATION FORM

(BRING ORIGINAL AND THREE COPIES TO TEAM REGISTRATION )

Name ___________________________________________________________ Phone (____) ______________
 
Address ____________________________________ City ______________________ State _____ Zip ______
 
Mother/Guardian _________________________________________ Business Phone (______) ____________
 
Father/Guardian __________________________________________Business Phone (______) ____________
 
High School Team _________________________________________________________________________
 
I have read and understood, and I agree with the Informed Consent and Release Authorization outlined below as it relates to my child.
 
Parent or Guardian Signature _______________________________________________________________
 
Insurance Company __________________________________________ Policy No. _____________________
 
Name of Physician ____________________________________________ Telephone ___________________
 
Existing Medical Condition (e.g., Asthma, Diabetes, etc.) ________________________________________
 
___________________________________________________________________________________________
INFORMED CONSENT AND RELEASE AUTHORIZATION FOR EMERGENCY TREATMENT

The undersigned, as the parent or legal guardian of the child listed in this application in consideration of the request and permission for my child to participate in the GOLDEN GATE SUMMER SHOOTOUT, hereby assume full responsibility for all risk of injury or loss which may result from my child's participation in this activity and hereby agree to hold harmless, release and forever discharge the GOLDEN GATE SUMMER SHOOTOUT FOUNDATION, INC. its Board of Directors, officers, agents, donors, volunteers, and employees, Redwood High School, Sir Francis Drake High School, Marin Catholic High School, Terra Linda High School, Dominican University of San Rafael, and College of Marin, their officers, agents, and employees (collectively called "Sponsors") from and waive any and all claims against said Sponsors, their officers, agents or employees by reason of accident, illness, injury or death of any person or persons, or damage to or loss or destruction of property arising or resulting directly or indirectly from my child's participation in the aforementioned program and occurring during said participation of any time subsequent thereto. The terms of this release shall serve as a release and assumption of risk for my child, heirs, executors and administrators, and for all of my family members.

I understand, agree and acknowledge that some activities may be of a hazardous nature and/or include physical and/or strenuous exercise or activity. With the full understanding of the facts, I understand that to the best of my knowledge, my child listed in this application has no medical, physical, mental or emotional health conditions which would hinder or prevent his/her active participation in the GOLDEN GATE SUMMER SHOOTOUT.

I understand that I am required to maintain and carry accident, medical insurance coverage for the child listed on this application, and verify that the coverage information submitted herewith is accurate and true.

In case of an emergency, and if I cannot be reached, I authorize the staff of the GOLDEN GATE SUMMER SHOOTOUT and/or any of its designated agents, to obtain whatever medical treatment he/she deems necessary for the welfare of my child listed in this application. I further understand and agree that I will be financially responsible for all charges and fees incurred in the rendering of said emergency treatment regardless of whether or not medical insurance would cover such charges and fees.