Player Name
*
First Name
Last Name
Parent Name
*
First Name
Last Name
Parent #2 Name (optional)
First Name
Last Name
Parent Email
*
Player Email (optional)
Parent Phone #1
*
(###)
###
####
Parent Phone #2 (optional)
(###)
###
####
Player Date of Birth
*
MM
DD
YYYY
Player Grade (Fall of 2024)
*
Player School (Fall of 2024)
*
Requested Jersey Size
*
Youth SM
Youth M
Youth L
Small
Medium
Large
X-Large
Gender, Pronouns (optional)
Ultimate Experience
*
Briefly describe player's experience playing Ultimate
Friends/Teammates who may also be attending:
Emergency Contact
*
First Name
Last Name
Emergency Contact Phone
*
(###)
###
####
Emergency Contact Relationship to Player
*
How how did you hear about the TUSC365 Back to School Clinic & Play Day?
*
Insurance Carrier Name
*
Insurance Carrier Phone
*
(###)
###
####
Primary Carrier:
Preferred Hospital
*
Medical Conditions / Considerations:
Are there any particular skills, strategies, or activities that you'd like to request during our Back to School Clinic and Play Day?
Liability Waiver
*
This acknowledges that we, the undersigned, parent(s) or legal guardian(s), recognize the potentially hazardous nature of the sport of Ultimate that an injury may be sustained. These injuries include, but are not limited to, PERMANENT DISABILITY, BLINDNESS, PARALYSIS and DEATH. In the event of such injury to the participant and we (I or my spouse or guardian) cannot be contacted, we give permission to qualified and licensed EMTs, physicians, paramedics, and/or other medical or hospital personnel to render appropriate treatment.
We (I) release the 2024 Texas Ultimate Summer Camp, its employees, its agents, its volunteers and its assigns from any personal injuries caused by or having any relation to this activity. We (I) understand that this release applies to any present or future injuries or illnesses and that it binds my heirs, executors and administrators.
I hereby authorize the Texas Ultimate Summer Camp to photograph and record my child’s likeness and participation for use in the above programming or parts thereof, including publication on the internet, published documents, and any other advertisements or promotional materials.
This release form is complete and signed of my own free will and with full knowledge of its significances. I have read and understand all of its terms.
Thank you so much for registering for our 2024 TUSC365 Back to School Clinic and Play Day! Do you have any questions for Coach Kepner and the TUSC Staff?