Date Form Completed *

MM

DD

YYYY

CIT's Name *

First Name

Last Name

Birthdate *

MM

DD

YYYY

Parent/Guardian *

First Name

Last Name

Primary Phone *

(###)

###

####

Secondary Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Parent/Guardian (2)

First Name

Last Name

Primary Phone

(###)

###

####

Secondary Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Name (1) *

First Name

Last Name

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Authorized to Pick Up *

Yes

No

Name (2)

First Name

Last Name

Phone

(###)

###

####

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Authorized to Pick Up

Yes

No

Physician’s Name *

First Name

Last Name

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Phone *

(###)

###

####

Address *

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Photography *

Photos may be taken and used to promote the summer camp at Germantown Athletic Club. By signing this, you, the parent/guardian, give permission for your child’s picture to be on the Club website, Facebook, Instagram, Twitter and/or other means of marketing such as newspaper advertisements.

Yes. I agree.

No. I disagree

Waiver / Release for Minor *

In consideration for being allowed to participate and/or enroll my child to participate in the activities relating to the Youth Activities, I hereby expressly reassume all risks and hazards, both known and unknown, incidental to my child’s participation in the Youth Activities and assume full responsibility for all risks of bodily harm and property damage resulting from or in connection with my child’s participation in the Youth Activities, including without limitation. I hereby voluntarily release, waive and forever discharge and agree to indemnify and hold harmless, the City of Germantown, its elected officials, officers, employees, agents, representatives and related persons (collectively the “Releasees”) and from any and all liabilities, claims, damages, injuries and losses, including attorney’s fees and courts costs, resulting from, arising out of or connected in any way with my child’s participation in the Youth Activities and related activities; and further agree to indemnify, defend and hold the Releasees harmless from and against any and all liabilities, claims, damages, injuries and losses, including attorney’s fees and courts costs, for personal injury or property damage to any person or entity resulting from or related to my child’s participation in the Youth Activities.

I agree.

Guardian Name *

First Name

Last Name