Annual Breaston/Mundy Youth Clinic
Email address *
Are you registering for Cheer or Football? *
Camper First Name? *
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Camper Last Name? *
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Camper Date of Birth? (Month/Date/Year) *
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Emergency Contact Information (First Name / Last Name / Phone #) *
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Medical Insurance Information
Disclaimer: Please note: We DO NOT provide health and/or medical insurance. Campers must rely on their parent/guardian's medical insurance for services. Insurance information must be included on this application. Minor sports injuries will be treated by an on-site athletic trainer. The Steven Breaston Foundation, along with The Breaston/Mundy Youth Clinic and its affiliates waive all responsibility for treatment of camp related injuries.
Does the camper have medical insurance? *
Does the camper have any medical conditions? *
Please note any medical conditions we should be aware of:
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Health Insurance Provider
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Agreement #
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Policy #
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Release and Waiver of Liability and Indemnity Agreement
In consideration of being permitted to participate in any way in the Breaston/Mundy Youth Clinic Program indicated below and/or being permitted to enter for any purpose any restricted area (here in defined as any area where in admittance to the general public is prohibited), the parent(s) and/or legal guardian(s) of the minor participant named below agree:
1. The parent(s) and/or legal guardian(s) will instruct the minor participant that prior to participating in the below Breaston/Mundy Youth Clinic activity or event, he or she should inspect the facilities and equipment to be used, and if he or she believes anything is unsafe, the participant should immediately advise the officials of such condition and refuse to participate. I understand and agreed that, if at any time, I feel anything to be UNSAFE; I will immediately take all precautions to avoid the unsafe area and REFUSE TO PARTICIPATE further.

2. I/WE fully understands and acknowledges that: (a) There are risks and dangers associated with participation in Breaston/Mundy Youth Clinic events and activities, which could result in bodily injury partial and/or total disability, paralysis and death. (b) The social and economic losses and/or damages, which could result from these risks and dangers described above, could be severe. (c) These risks and dangers may be caused by the action, inaction or negligence of the participant or the action, inaction or negligence of others, including, but not limited to, the Releases named below. (d) There may be other risks not known or are not reasonably foreseeable at his time.

3. I/WE accept and assume such risks and responsibility for the losses and/or damages following such injury, disability, paralysis or death, however caused and whether caused in whole or in part by the negligence of the Releases named below.

4. I/WE HEREBY RELEASE, WAIVE, DISCHARGE AND COVENANT NOT TO SUE the Breaston/Mundy Youth Clinic facility used by the participant, including its owners, managers, promoters, lessees of premises used to conduct the Breaston/Mundy Youth Clinic event or program, premises and event inspectors, underwriters, consultants and others who give recommendations, directions, or instructions to engage in risk evaluation or loss control activities regarding the Breaston/Mundy Youth Clinic facility or events held at such facility and each of them, their directors, officers, agents, employees, all for the purposes herein referred to as “Releasee”...FROM ALL LIABILITY TO THE UNDERSIGNED, my/our personal representatives, assigns, executors, heirs and next to kin FOR ANY AND ALL CLAIMS, DEMANDS, LOSSES OR DAMAGES AND ANY CLAIMS OR DEMANDS THEREFORE ON ACCOUNT OF ANY INJURY, INCLUDING BUT NOT LIMITED TO THE DEATH OF THE PARTICIPANT OR DAMAGE TO PROPERTY, ARISING OUT OF OR RELATING TO THE EVENT(S) CAUSED OR ALLEGED TO BE CAUSED IN WHOLE OR IN PART BY THE NEGLIGENCE OF THE RELEASEE OR OTHERWISE.

5. I/WE HEREBY acknowledges that THE ACTIVITIES OF THE EVENT (S) ARE VERY DANGEROUS and involve the risk of serious injury and/or death and/or property damage.
Each of THE UNDERSIGNED also expressly acknowledges that INJURIES RECEIVED MAY BE COMPOUNDED OR INCREASED BY NEGLIGENT RESCUE OPERATIONS OR PROCEDURES OF THE RELEASEES.

6. EACH OF THE UNDERSIGNED further expressly agrees that the foregoing release, waiver, and indemnity agreement is intended to be as broad and inclusive as is permitted by the law of the Province or State in which the event is conducted and that if any portion is held invalid, it is agreed that the balance shall, notwithstanding continue in full legal force and effect.

7. On behalf of the participant and individually, the undersigned partner(s) and/or legal guardian(s) for the minor participant execute this Waiver and Release. If, despite this release, the participant makes a claim against any of the Releases, the parent(s) and/or legal guardian(s) will reimburse the Releasee for any money, which they have paid to the participant, or on his behalf, and hold them harmless.

I HAVE READ THIS RELEASE AND WAIVER OF LIABILITY, ASSUMPTION OF RISK AND INDEMNITY AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND HAVE SIGNED IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT, ASSURANCE, OR GUARANTEE BEING MADE TO ME AND INTEND MY SIGNATURE TO BE COMPLETE AND UNCONDITIONAL RELEASE OF ALL LIABILITY TO THE GREATEST EXTENT ALLOWED BY LAW.

Event: Breaston/Mundy Youth Clinic
I certify that I have read the release and waiver of liability and indemnity agreement and agree to the terms herein *
Agreement
I hereby authorize the staff of The Steven Breaston Foundation, The Breaston/ Mundy Youth Clinic and any of it's affiliates to act for me in accordance with their best judgment in any emergency requiring medical attention and I hereby waive and release the camp from any and all liability for any injuries or illness incurred while at camp.

I have no knowledge of any physical impairment that would be affected by the above named camper's participation in the camp program, as outlined on this website. The Steven Breaston Foundation, The Breaston/ Mundy Youth Clinic and any of it's affiliates have my permission to use photographs and/or video recordings of my child publicly to promote its programs. I understand that the images and/or video may be used in print publications, online publications, presentations, websites, social media and other similar forms of use. I also understand that no royalty, fee or other compensation shall become payable to me by reason of such use.
I certify that I have read the agreement and agree to the terms herein *
Name of Parent / Guardian Completing this Form *
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E-Signature (By entering your initials in the box below, you are effectively providing your signature, indicating that all the information on this form is true and accurate, to the best of your knowledge.) *
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