Camper Name *

First Name

Last Name

Parent / Guardian Name *

First Name

Last Name

Parent / Guardian Phone *

(###)

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Parent / Guardian #2 Name (optional)

First Name

Last Name

Parent / Guardian #2 Phone (optional)

(###)

###

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Camper Date of Birth *

MM

DD

YYYY

Emergency Contact *

First Name

Last Name

Emergency Contact Phone *

(###)

###

####

Insurance Company Phone

(###)

###

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Who is the primary carrier named on the camper's insurance?

First Name

Last Name

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 2025 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.

I acknowledge that I have read and agree to the TUSC365 Liability Waiver.

I do NOT agree to the TUSC 365 Liability Waiver.