Grace Church of Mentor Ultimate Challenge Registration Form

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Ultimate Challenge 2010 Registration

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Personal Information

First:

Last:

Address:

City:

Email:

Birthdate:

Grade Completed:

Age:

Phone:

Emergency Phone:

Sport	Gender	Team
Basketball (3 on 3)	Guys Girls	Add me to a team I have a team
Soccer (6 on 6)	Guys Girls Coed	Add me to a team I have a team
Volleyball (6 on 6)	Guys Girls Coed	Add me to a team I have a team
Flag Football (7 on 7)	Guys Girls Coed	Add me to a team I have a team

Parent or Guardian Information

Parent information: I am the parent of the above minor and I certify that I am over 18, or I am an 18 year old competitor. I understand that checking the boxes and filling in my information constitutes legal agreement and that I may be contacted to verify my agreement.

Name:

Phone:

Email:

Consent for Medical Treatment:

In the event that reasonable attempts to contact a parent or guardian has been made without success, I give my consent for the administration of treatment deemed necessary by a licensed physician or dentist and the transfer of my child(ren) to any reasonably accessible hospital. The following are facts concerning my child(ren)s medical history to which a physician should be alerted:

I DO NOT give my consent for emergency medical treatment of my child. In the event of an emergency, I wish the church staff to take no action or to do the following:

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Parental Permission Form

Ultimate Challenge 2010 Registration