I plan to attend the MSY Adult Referee Academy on June 26-27, 2007

    

Particpant's Name

I am 18 years of age or older.
 

Camper's Contact Information

Address

 

City

State

Zip

Contact Information
 

Phone
 
                    (include area code)

Cell Phone

                   (include area code)
 

E-mail address

Emergency Contact Name


Emergency Contact Phone #

                   (include area code)

Credit Card PAYMENT Information
If same as participant contact information click:  Yes 

 If NOT "yes" provide the following
(We need this information that we can match up this form with your payment)
* You must provide this information
 

*Name as it appears on the credit card


*Phone # associated with your credit card

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You MUST read & then provide your name per the following:

Participant waiver
* You must provide this information.
 

In consideration of allowing participation in Metro Sports Youth, I/we hereby knowingly release and forever discharge Time Warner Cable and it employees and agents from any and all liability, actions, lawsuits, claims, demands and expenses resulting, directly or indirectly, from loss of life, personal injuries, property damage, or other damage suffered by the named participant in connection with participation in Metro Sports Youth, regardless of the cause of the injury or damage, including but not limited to negligence of Time Warner Cable, its affiliates, and the employees and agents of each or actions of other participants in the activity. I/we understand that transportation may be provided for certain portions of the program, and authorize participant to be conveyed by such transportation.
 

*By typing my name  in the following box, I hereby state that I am that I am age
18 or over and that I  have read, understand and accept the above stated terms.

The named participant does hereby grant to any hospital, emergency center, doctor, nurse, and/or emergency medical services provider, authority to provide emergency medical treatment to my child.  Should the attending physician or provider determine that life-saving surgery or other life-saving procedures are necessary, I do hereby grant permission to administer necessary life-saving surgery or other life-saving procedures. 

*By typing my name  in the following box, I hereby state that I am that I am age
18 or over  and that I  have read, understand and accept the above stated terms.

Nex

Once you have completed the above form to your satisfaction click 

THANK YOU!    We are looking forward to seeing you
at the MSY Referee Training Academy!