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Club Member's Name
Last Name First __________________________________________________________________
Father's Name ________________________ Mother's Name _____________________
Emergency Contact Information ____________________________________________
|Home Phone Number
|Business Phone Number
|Club Member's Date of Birth ____/____/____||Current age ____||Sex : M ____ F ____|
Club dues are $2.00/meeting. You may wish to bring other money for the purchase of sodas or other items that will be available through the club store.
I hereby authorize the staff at the KingArthur.com and and Urban Assault Camp, Inc. to act for me according to their best judgement in any emergency requiring medical attention, and I hereby waive and release the Club from any and all liability for any injuries and illnesses incurred while at the Club. I understand that participation in Inline Skating, Skateboarding, and many other club activities involves motion, rotation, and height in a unique environment and as such carries with it the risk of injury and possibly death. I further waive, release, discharge, and covenant not to sue KingArthur.com Urban Assault, or their assigns for any or all injuries or damages of any kind as a result in taking part in this event and all related activities. The Club is not responsible for personal items that are lost, stolen, or damaged. All medical expenses incurred will be the responsibility of the club member or the club member's family. In lieu of medical certificate signed my a medical doctor, I have no knowledge of any physical or mental impairment that would be affected by the named club member's participation in the Club program, as outlined in the brochure, which I have read. I also understand the Club retains the right to the use of photographs, videotapes, motion picture recordings, or any other recording of this event for publicity, advertising, or any legitimate purpose.
|Insurance Company's Name & Your Policy #_________________________________________________________|
|Family Doctor's Name & Phone Numer _____________________________________________________________|
|Club Member's Social Security Number (emergency room may require it)_________________________|
Please Sign Here
Parent or Guardian (Signature) ___________________________________________________________ Date _____________________
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