Medical Release

The named player has my permission to participate in this program. In case of an emergency,

I understand that every attempt will be made to contact me. If contact is unsuccessful, I give permission to the attending training staff to render treatment to the participant, including hospitalization. Any expense arising from injury is the responsibility of the person signing below. I hereby authorize the staff of the Masters Football Players Clinic to provide care that includes routine diagnostic procedures (i.e. x-rays, blood & urine tests) and

medical treatment as necessary to my minor son/daughter.

PARTICIPANTS NAME:_____________________________________________________

Please list any physical conditions that the athletic trainer and staff should be aware of

( allergies, recurring illnesses, disabilities, chronic illness, asthma, insect allergies, etc.)

List Condition(s): ____________________________________________________________

___________________________________________________________________________

Month/Day/Year of most recent Tetanus: __________________________________________________

If more than ten years ago, a booster shot is recommended.

I agree to indemnify and hold harmless the staff of the Masters Football Players Clinic and  the City of Waltham, its agents and employees, from any and all liability in connection with these activities.

Parent/Guardian Signature:________________________________Month/Day/Year:_________________

Emergency Notification: __________________________________Tel# (       )_____________

Pager #___________________________Cell # (        )__________________________

Please List your health insurance carrier and policy # below:

Ins. Co. _____________________________________Policy #___________________________

All players shall submit a physical examination form from their doctor with the application prior to the clinic.

ALL INFORMATION ABOVE MUST BE COMPLETED TO ATTEND CLINIC.  Form 2008

Application for the Masters Football Players Clinic;   July 13 to 17th, 2008

Name:__________________________________________________________________

Address:________________________________________________________________

City:___________________________State:____________Zip Code:_______________

Phone# (             ) ___________________________________DOB_________________

School: _____________________________________Grade_____________as of Sept. 2008

E-Mail:________________________________________Shirt Size:__________________

Location: Harding Field at Waltham High School.

Fee:

To insure your reservation, a $180.00 fee is required with your application.

____ place check here if needed to rent a helmet for an additional $35.00

This camp historically sells out. Sign up early and don't miss out.

Please send checks to:John Bandini

Champion Coach Inc.

P.O. Box 550158

No. Waltham, MA 02455-0158

Tel.# 781-942-4521

Choose one offensive & one defensive position: Please check

Offense:Defense:

___Offensive Line___Defensive Line

___Tight End ___Defensive End

___Receiver  ___Defensive Back

___Quarterback    ___Inside Linebacker

___Running Back  ___Outside Linebackers

List Weakness:_____________________________________________________________

How did you hear about Clinic?________________________________________________

Your cancelled check is your receipt.

THERE IS A $35 CANCELLATION FEE.