2^nd Annual Tom Vadas Memorial

 

 

Dodgeball Tournament

 

TEAM REGISTRATION FORM

EVENT DATE:Saturday May 9^th TEAM CHECK IN: Youth by 2:30 pm, Adult by 6:00 pm

Registration Deadline is: Friday May 1^st

To register, ALL of the following must be submitted together.

1. This form completely filled out

2. A medical form for each participant

 

Team Name ________________________________________________________________

 

Team Captain___________________________Phone______________E-Mail__________

Number of participants 6 7 8

Player Name Phone #         E-Mail                Med Form               Amount Raised        

 

1. ______________________________________________________________________

 

2. ______________________________________________________________________

3. ______________________________________________________________________

4. ______________________________________________________________________

5. ______________________________________________________________________

6. ______________________________________________________________________

7. ______________________________________________________________________

8. ______________________________________________________________________

 

For more information contact:  Kim Glass 781-2729 kglass@mmhs-fla.org

or Sandie Vadas 772-528-3204  jersey-girl1@live.com

 

You can make donations online at www.mmhs.com

 

Check out: http://dodgeforthecure.blogspot.com/

 

 

MEDICAL RELEASE FORM AND LIABILITY WAIVER 

I Hereby give my permission for any and all medical attention necessary to be administrated to myself or child participant listed below, (NAME)______________________________________________ 

In the event of an accident, injury, sickness, etc., under the direction of the persons listed below, until such time as I may be contacted. I assume all financial responsibilities for any expenses incurred. 

My Name:_________________________________________________ 

My Address:______________________________________________ 

Home Phone:_________________Cell Phone:__________________ 

My Insurance Company:_____________________Policy#________ 
 

In the event I cannot be reached, any of the following people may be designated to act in my behalf: 

Adult Volunteer, Adult Audience Adult participant, Other present at event or Emergency Contact Person: 
 

Contact Name:_________________________________________________ 

Phone Number:_________________________________________________ 
 

Physician Name:__________________________ Phone#______________ 
 

I understand and accept that the risk of injury is possible while participating in athletic activities. I authorize the directors, committee personnel and volunteers of Dodge for the Cure to act according to their best judgement in any emergency requiring medical attention. I agree to indemnify and hold harmless anyone associated with Dodge for the Cure for all medical and dental expenses incurred as a result of participation in Dodge for the Cure tournament, event, any company or persons affiliated with Dodge for the Cure or use of the Jensen Beach High School Facilities. I hereby acknowledge that Dodge for the Cure Event, its committee, referees or representatives cannot be held responsible for any injury to my son/daughter. 

Signature

(Parent/Guardian)______________________________Date_______________