Consent Form: Pasadena Water Polo Middle School Spring 2024 Camp @Muir (April 24 - May 24, 2024, Wednesdays & Fridays 6:00-7:30 pm)
Please complete this form BEFORE arriving to your first practice. Practices are every Wednesday & Friday from 6:00 pm to 7:30 pm at the Muir Pool (corner of Forest & Toolen). Camp begins April 24 and ends May 24, 2024.
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Email *
Player First Name *
Player Last Name *
Grade Level for Fall 2023 *
Current School
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Which high school will your child attend?
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Race/Ethnicity - Check all that apply. (Optional) (In an effort to raise funding for the program we apply for grants.  Funders typically request player demographic data. This data is anonymous and optional to provide.)
T-Shirt Size (Adult sizes)
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How did you hear about this program?
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USA Water Polo Membership Number
Parent/Guardian Full Name *
Parent/Guardian Phone # *
Parent/Guardian Email *
CONSENT: I do hereby give my consent for my child to participate in Muir Water Polo Camp.  I understand that the coaching staff, the school and the school district are relieved of all responsibility in case the participant is injured while participating at the camp.  I understand and acknowledge that some activities, by their very nature, pose the potential risk of serious injury (sprains/strains, fractures, unconsciousness, paralysis, loss of eyesight, etc.) or death to individuals who participate in such activities.  I further understand and acknowledge that participation in the camp is completely voluntary.  I understand and acknowledge that in order to participate in the camp, I and my child agree to assume liability and responsibility for any and all potential risks which may be associated with participation in such activities.  I understand, acknowledge, and agree that the school, the coaching staff, or volunteers shall not be liable for the injury/illness suffered by my child which is incident to and/or associated with preparing for and/or participating in this activity.  I acknowledge that I have carefully read this, Parental Consent and Assumption of Risk for Participation Mustang Water Polo Camp form and that I understand and agree to its terms. *
Typing my full name below will serve as my e-signature and consent for participation.
EMERGENCY MEDICAL TREATMENT: Should it be necessary for my child to have medical treatment while participating in this camp, I hereby give the camp personnel permission to use their judgement in obtaining medical services for my child and I give permission to the physician selected by the camp personnel to render medical treatment deemed necessary and appropriate by the physician,  I understand that the camp has no insurance covering such medical and hospital costs incurred by my child and therefore any costs for such treatments shall by my sole responsibility. *
Typing my full name below will serve as my e-signature and consent to the emergency medical treatment terms.
PHOTO RELEASE: I consent to have my child's photo taken and possibly used in marketing, social media, or other promotion materials for the middle school program. *
Emergency Contact #1 (Name & Relation)
Phone Number (contact #1)
Emergency Contact #2 (Name & Relation)
Phone Number (contact #2)
Please list anything the staff should know about your student (allergies, medications, personal issues, etc.)
Is your player NEW or RETURNING to the middle school water polo camp? *
Insurance Carrier (Fill out only if player is NEW to the camp or if your insurance has changed)
Insurance ID # (Fill out only if player is NEW to the camp or if your insurance has changed)
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