St. John’s Lutheran School Basketball Camp
Winston-Salem, NC
Parent Permission
Parent/Guardian:
Relation:
Street Address:
City:
Camper Name:
Age:
Experience (If any):
State:
Gender:
Zip Code:
Home Phone:
Work Phone:
E-mail:
Emergency Contact:
Number:
Risk of Injury: We acknowledge and understand that there is a risk of injury involved in athletic participation. We agree
to follow the rules of the sport and the instructions of the coach in order to reduce the risk of injury to the student and
other athletes. However, we acknowledge and understand that neither the coach nor St. John’s Lutheran can eliminate
the risk of injury in sports. Injuries may and do occur. Sports injuries can be severe and in some cases may result in
permanent disability or even death. We freely, knowingly, and willfully, accept and assume the risk of injury that might
occur from participation in athletics.
Release: St. John’s Lutheran sports camps are controlled and supervised by St. John’s Lutheran School. I (we), the
undersigned, for ourselves, our heirs, executors and administrators, waive, release and forever discharge St. John’s
Lutheran School staff, athletic coaches, parents and volunteer coaches, and other employees from any and all liability,
claims, demands, actions, and causes of actions whatsoever arising out of or related to any loss, personal injury or
property damage that may be sustained or occur during participation of this camp.
Insurance: St. John’s requires that all students who participate in athletics be adequately covered by medical or accident
insurance. We certify that we have purchased and will maintain in full force and affect during the participation in this
sports camp. The following Insurance policy:
Name of Insurance Company
Policy No:
Street Address:
City:
Group No:
State:
Zip Code:
Policy term, From: To:
Certification and Medical Authorization. We certify that all of the information provided by us on this form is correct. We
agree to abide by the rules of St. John’s Lutheran School. We give our consent for the participant to receive a medical
screening examination prior to participation in athletics. If the participant is injured while participating in athletics and St.
John’s Lutheran School is unable to contact the parent, we grant St. John’s Lutheran School permission and the authority
to obtain necessary medical care and/or treatment for the student’s injury, including first aid, medical or surgical
treatment recommended by a physician and we accept the financial responsibility for such medical care or treatment.
Code of Sportsmanship: It is recognized that St. John’s athletic events should be conducted in such a manner that good
sportsmanship prevails at all times. Every effort should be made to promote a climate of wholesome competition.
Unsportsmanlike acts will not be tolerated.
I, the undersigned student and parent, have read this document and understand all of the expectations for athletic
participation at St. John’s Lutheran School.
Student:
Date:
Parent/Guardian:
Date:
Additional Information:
Payment is due when form is turned into the school office:
St. John‘s Lutheran Church and School * 2415 Silas Creek Parkway * Winston-Salem, NC 27103 * Phone 336-725-1651 ext. 423 *
[email protected] * www.stjohnsfalcons.org
St. John’s Lutheran School Basketball Camp
Winston-Salem, NC
For office use only:
DATE ________
RECEIVED BY ________________
AMT PAID __________
CHECK# _____________
CASH ________
Copy of Check_____________
St. John‘s Lutheran Church and School * 2415 Silas Creek Parkway * Winston-Salem, NC 27103 * Phone 336-725-1651 ext. 423 *
[email protected] * www.stjohnsfalcons.org