Player Name
*
First Name
Last Name
Parent / Guardian Name
*
First Name
Last Name
Parent / Guardian #2 Name (optional)
First Name
Last Name
Parent / Guardian Email
*
Player Email (optional)
Parent / Guardian Phone
*
(###)
###
####
Parent / Guardian Phone #2 (optional)
(###)
###
####
Player Date of Birth
*
MM
DD
YYYY
Player Grade (Spring 2025)
*
Player School (Spring 2025)
*
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:
USA Ultimate Membership ID Number:
*
If you created or renewed your USA Ultimate Membership specifically for this event, please identify the cost of that membership here:
If you created or renewed your USA Ultimate Membership specifically for this event, please identify your preferred method of reimbursement:
Options include Venmo, Paypal, Check, or Cash. Please include any details necessary (i.e. payee, mailing address, handle, etc.).
We'll be serving lunch at this event! Please make any food-related suggestions or requests here.
Please identify suggestions and preferred items as well as any food allergies, medical conditions, or dietary restrictions.
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:
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.
Check below to confirm that you have a current USA Ultimate membership.
*
Your registration is NOT COMPLETE until you have both a current USA Ultimate membership AND you have submitted this registration form.
Thank you so much for registering for our 2024 TUSC365 & AU GNB Play Day 2025! Do you have any questions for Coach Kepner and the TUSC Staff?