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IPV Summer Camp/Lesson Registration & Waiver Form
Participant Information:

Athletes Name: _________________________ Parent Name:________________________

Address: _____________________________  City__________________Zip_____________

Phone: ________________ Parent Cell or Emergency Contact: ______________________

Email Address: ________________________@ ________________

School: _______________________________ Grade in fall: ___ B-day: _________

Height:______Hand:_____Preferred Position (S/OH/MH/Ds...)____________________

VB Experience: ____________________________________________________________

Summer Camp Codes: (Daytime: JH-Def, JH-Off, VL; Evening:14U-S, 12U-AS, 14U-AS) __________
School Prep Lessons: indicate Type- serve ___ defense ___ offense ___ (July-October)

Dates: ______ _______ ______ _______ _______ Age Level- JH___HS ____

Amount Due:__________ Check #:_______ Date Paid:_____________

I grant permission for clinic/lesson photos (including my daughter) to be posted on the Illinois
Performance Volleyball, Inc. (www.ipvbc.com), or IPV Social Media sites.
I grant Illinois Performance Volleyball, Inc. (IPV) permission to contact me about future clinics,
lessons, volleyball programs and tryouts.

I hereby grant permission for my daughter _______________________________, to attend

clinics/lessons offered by Illinois Performance Volleyball, Inc. My daughter has no medical condition
that would interfere with her participation in the clinic. I release the clinic/lesson instructors,
clinic/lesson facility 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: _________

Illinois Performance Volleyball, Inc
Last Updated on Monday, 09 April 2018 21:40