Summer Clinic Registration & Waiver Form
Participant Information:
Athletes Name: _________________________ Parent Name:________________________
Address: _____________________________City__________________Zip____________
Phone: ________________ Parent Cell or Emergency Contact: ______________________
School: ___________________________________ Grade in fall: _____
Preferred
Position: ________________B-date: _________ T-shirt Size: ____
Email Address: ________________________@ _______________________________
Clinic Information:
Location: Walker Complex,
Beginner Level- 7-9pm, Cost- $125.00 *Cost includes T-shirt
Beginner Level Dates: (Fri.) July 11, 18, 25, & Aug. 1, 8
Intermediate Level- 6-8pm, Cost- $250.00 *Cost includes T-shirt
Intermediate Level Dates: (Tues. & Thurs.) July 8, 10, 15, 17, 22, 24, 29, 31 & Aug. 5, 7
Advanced Level- 8-10pm , Cost- $250 *Cost includes T-shirt
Advanced Level Dates: (Tues. & Thurs.) July 8, 10, 15, 17, 22, 24, 29, 31
Clinic attending: Beginner Level ____ Intermediate Level
____ Advanced Level _____
Waiver:
I grant
permission for clinic photos (including my daughter) to be posted on the Illinois
Performance Volleyball, Inc. website. (www.ipvbc.com)
I grant
Illinois Performance Volleyball, Inc. (IPV) permission to contact me about
future
clinics, lessons, volleyball conditioning or tryouts.
I hereby grant
permission for my daughter _______________________________, to attend
the 2008 Summer Volleyball Clinic run by Illinois Performance Volleyball, Inc. and
Next Level Athletes, Inc (Speed, Inc). My daughter has no medical condition that would interfere with
her participation in the clinic. I release the clinic instructors, clinic facility (Walker Complex, Lisle)
and all staff from any liability from injuries which may occur.
Parent Signature: _____________________________________ Date: ______________
If, during the course of my daughter’s/son’s activities in volleyball, she should become ill or sustain an
injury, I do authorize the Illinois Performance Volleyball, Inc. staff to obtain emergency medical/dental
care. I will assume financial responsibility for the bills incurred through my insurance company.
Parent Signature: _____________________________________ Date: ______________
I do not authorize emergency medical/dental care for my daughter/son.
Parent Signature: _____________________________________ Date: ______________