Southwest Academy March Break Camp
Regina Mundi Catholic College / March 16th - 20th 9:00 am - 5:00 pm
Athlete's Full Name: *
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Athlete's School: *
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Athlete's Club Organization: *
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Date of Birth *
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City: *
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Parent 1 Full Name *
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Parent 1 Contact Phone Number *
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Parent 1 Contact E-mail *
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Parent 2 Contact Name *
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Parent 2 Contact Phone Number *
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Additional Emergency Contact
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Additional Emergency Contact Phone Number
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Please list any medical conditions Southwest Academy should be aware of:
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How did you hear about us?
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Payment $225: T shirt Included *
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Release and Waiver: I HEREBY RELEASE, WAIVE AND FOREVER DISCHARGE Southwest Academy, Rocca Elite Academy and all other associations, coaches, event organizing bodies, sanctioning bodies, and sponsoring companies and all their respective agents, officials, servants, contractors, representatives, successors and assigns OF AND FROM ALL claims, demands, damages, costs, expenses, actions and causes of action, whether in law or equity, in respect to death, injury, loss or damage to the applicants person or property, HOWEVER CAUSED, ARISING OR TO ARISE by reason of the applicants participation in this program whether as a spectator, participant, competitor or otherwise, at any time. AND NOT WITHSTANDING that same may have been contributed to or occasioned by negligence of any of the aforesaid. This agreement shall bind my heirs, executors, assign, and representatives. I FURTHER HEREBY UNDERTAKE TO HOLD AND SAVE HARMLESS and AGREE TO INDEMNIFY all the aforesaid from and against any and all liability incurred by any or all of them arising as a result of or in any way connected with the applicant's participation with Southwest Academy/Rocca Elite Academy. I WARRANT that the applicant is physically fit to participate in and be involved in the basketball program. I hereby agree that my name and photograph may be used in associated photographs for Southwest Academy and Rocca Elite Academy promotional material. BY SUBMITTING THIS APPLICATION, I ACKNOWLEDGE HAVING READ, UNDERSTOOD, AND AGREED TO THE WAIVER, RELEASE, AND INDEMNITY. *
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Acknowledge and accept above release and waiver (enter parent/guardian full name): *
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