$150.00 - Checks Should Be Made Payable to Danny Skeltonand Sent To

$150.00 - Checks should be made payable to Danny Skeltonand sent to:

Coach Danny Skelton

11 Kilbeggan Green

Nottingham, MD 21236

*There are limited spots available. To reserve your spot please email Coach Danny Skelton at *

ThisRegistrationFormshallbecompletedbytheparticipant,oriftheparticipantisaminor/child,bythelegalauthorizedparentorguardianofsuch minor/childparticipant.

EnrollmentInformation:

Participant’sName:

Age: DateofBirth:

StreetAddress: City/State: ZipCode:

Parent’sE-Mail:

HomePhone:

CellPhone:

T-Shirt Size- PLEASE CIRCLE ONEAdult Sizes (Small – Medium – Large) Children Sizes (Small – Medium – Large)

Emergency/HealthIssues:

In caseof emergency,pleasenotify(ifminor/childparticipant,provideparent’sinformationorGuardian,asappropriate).

Name: Relationship: HomePhone CellPhone

Name: Relationship: HomePhone CellPhone

Physician’sName:

Physician’sPhone:

NameofMedicalProvider:

Dateoflasttetanusimmunization:

Anymedical,psychological,or behavioralconditionsweshouldbeawareof (beestings,foodallergies,etc.)?

1.Are thereanymedicalor healthfactorsor limitationsthatmightaffectparticipant’s performancein theactivity?

Yes

No

2.Isparticipanttakinganymedicationsor havea conditionthatmayaffectparticipant’ssafetyorperformanceinthe activity?

Yes

No

3.Is participantrequiredanyspecialaccommodations(duetodisability)to participateintheactivity?

Yes

No

Ifyes,pleaseexplain:

Incaseofinjuryoremergency,Iformyselfand/orparticipant(ifparticipantisminor/child),andmypersonalrepresentatives, heirsandassigns, (severallyandcollectively “I”forthisregistrationform)givepermission foranactivityrepresentativetocall911andtransportparticipant toahospital. IshallinformtheRecreation Council,inwriting,ofanymedicalorhealthconditionsofparticipantthatoccursordevelops andwhichcouldaffect participant’ssafety,performanceor participationin orthroughouttheactivity.

Signatureofparticipantor,ifminor,ofparent/guardian: Date:

ACKNOWLEDGEMENT,WAIVERANDRELEASEOFLIABILITY:

Iherebyconfirmparticipantisingoodhealthandabletoparticipateintheactivity.

Iacknowledgetheactivitymayinvolveriskanddangerofbodily

injuryordeath. Ifullyaccept andacknowledgetheactivitiesmayinvolverisk,andIhereby assumetheriskandresponsibilityforalldangersandrisks associatedwiththeparticipantintheactivity.I furtherunderstandthatconcussioninformationisavailableat

Iacknowledge BaltimoreCounty,Maryland,Dulaney High School,andtheirrespectiveemployees,directors,officers,volunteers, membersandany otherparticipant, entity,partyorpersoninvolvedinanyregardwiththeactivityortheactivitypremises andtheirrespectiveagents,personal representatives,heirs,employees,contractors, successorsandassigns(eachon“activityrepresentative”andcollectivelythe“activityrepresentatives”), shallnotberesponsible orliableinanyregardormannerforanyandallpropertydamageorbodilyinjury(includingseriousphysicalinjuryoreven death)incurredbyparticipantoranypartyrelatedtheretoasa resultofhis/herparticipationintheactivity.

Ihaveread,fullyunderstand,andherebyfreelysign,approveof,andagreetothetermsofthisregistrationform.

Iherebyunconditionallyrelease

discharge,covenantnottosue,waivemyrightsandremedies,andagreetoholdharmlesstheactivityrepresentativesfromanyandallclaims,costs, demands,losses,damages,orexpensesassociated with,inwholeorinpart,participant’sinvolvement withtheactivity. Icertifyallanswersand informationprovided onthisregistrationformaretothebestofmyknowledgetrueandcorrectthroughouttheactivity. Ishallinformtherecreation councilinwritingifanyinformation providedinthisregistration formisincorrectorchangesthroughthecourseoftheactivity.Iunderstand Baltimore Countyand/ortherecreationcouncil donotperformcriminaland/orbackground checksonactivityrepresentatives. Ishallpresentagovernment- issued photo identificationcardincluding,butnotlimitedto,mydriver’slicense,passport,orUnitedStatesVisatotheactivityrepresentativeforreview, ifrequested,atthetimeI submitthisregistrationformtotherecreationcouncil.

SignatureofParticipant(ifover18)ORofparent/guardian(ifunder18): Date: