PARENTAL CONSENT: Before medical operations and procedures can be performed on minors, the law requires parental permission. As APPLICATION parent or guardian you are asked to sign the following consent form that will allow medical procedures to be carried out promptly and without unnecessary delay. Except in emergencies, no medical operations will be performed without the parent or guardian being contacted and informed of the situation. Name:____________________________________________________________ As the minor’s parent or guardian, I have actual knowledge and appreciate that there are risks of bodily injury, such as cuts, sprains, concussions, and broken bones from one’s participation in football camp activities, and hereby voluntarily consent to the minor’s participation in football camp activities and assume all risks of possible injury. Address:__________________________________________________________ Signature _______________________________________________________________________ Relationship __________________________ City:_______________________________ State:__________ Zip:______________ RELEASE & WAIVERS OF CLAIMS: In consideration of my child/dependent being permitted to attend and participate in football camp activities, I, for myself, my child/dependent, my heirs, and personal representatives, do hereby waive, release, and discharge forever any and Home Phone: ______ - __________________ Camper Cell: ________________ all claims for damages for bodily injury or death or damage or loss of property, that I or my child/dependent may have or that may occur subsequent to me or to my child/dependent against the camp operators, its officers, employees, agents, volunteers, representatives; and in consideration of the camp being offered at it premises, and The Board of Trustees of The University of Alabama and its trustees, officers, Age:______ Grade: (Fall 2010)______ Email: _____________________________ employees, and agents (the “University”) arising from or attributable to my child/dependent’s attendance at and participation in football camp activities. Further, I hereby give to the University and its agents and representatives permission and a release to use as necessary my School Attending (2010) ______________________________________________ child’s/dependent’s name and photograph to promote and advertise the football camp for a period of two years after the date of this release. I have read, or have had read to me, this release and waiver of claims statement and understand and voluntarily agree to its provisions. Head Football Coach ________________________________ Shirt Size: _________ Signature of Parent/Guardian _________________________________________________________________________Date _______________ Child’s/Dependent’s Name & Telephone Number__________________________________________________________________ Parent/Guardian’s Name: ____________________________________________ AIRPORT PICK-UP (Overnight camp only): Is airport pick-up service needed? Yes ❏ No ❏ If yes, we require that you send a copy of your Daytime Phone _____ - ________________ Evening Phone: ___________________ child’s airline schedule information including carrier, times, and flight numbers. Birmingham Airport pick-up can be arranged for additional $30.00 fee. (payable with registration) Signature ________________________________________ Roommate request (list only one): __________________________________________ MEDICAL HISTORY: (To be completed by parents/guardian) Both must be (1) pre-registered for camp, and (2) request each other as roommates for preference to be honored.) Is there a known history of: A.) Birth Deformities (one eye, one kidney) etc. Yes ❏ No ❏ B.) Medical Conditions currently under treatment Yes ❏ No ❏ C.) Pre-existing injury currently under treatment Yes ❏ No ❏ D.) Fractures or other disability type injuries Yes ❏ No ❏ Position you want to play in camp (circle only one): RB QB WR TE OL DL LB DB E.) Allergy (drugs, food, asthma, etc.) Yes ❏ No ❏ F.) Mental Disorder – Yes ❏ No ❏ G.) Known past illness of more than one week’s duration Yes ❏ No ❏ Full payment is due at time of application and is non-refundable. No partial payments are H.) Contacts or glasses Yes ❏ No ❏ accepted. Confirmation card will be sent upon receipt of registration and payment. Explain above questions answered “Yes”________________________________________________________________________________________________________________ I hereby state that the camp operators, its officers, employees, agents, volunteers, representatives, and the Board of Trustees of The University of Alabama is not responsible for any pre-existing injury or reoccurrence or aggravation of any disclosed or undisclosed pre-existing injury or illness of the above camper. Signature of Parent/Guardian ____________________________________________________________________ Date ________________ Please check the session(s) you will attend: MEDICAL STATEMENT: Attach a copy of your previous year’s football physical to this form OR have your physician fill out and sign the following medical statement. ❏ High School I (Grades 9-12): June 6-9 $360.00 (Overnight) $260.00 (Day camper) MEDICAL STATEMENT: I hereby certify that I have examined____________________________ and found him physically fit to attend and participate in the Nick Saban Football Camp, and I know of no impairments which would limit his participation in football camp activities. ❏ Youth camp (Ages 8-14): June 13-16 Comments_________________________ Date of last tetanus immunization_________ Date examined________ Physician_________________ $360.00 (Overnight) $260.00 (Day camper) Are you currently taking any medicine?__________________________________________________________________________________________________________ ❏ High School II (Grades 9-12): July 18-21 $360.00 (Overnight) $260.00 (Day camper) To enroll: Complete and mail along with full payment to: ❏ Kicking Camp: June 12 $50.00 Nick Saban Football Camp, LLC ❏ 7 on 7: June 19 $50.00 P.O. Box 2865 • Tuscaloosa, AL 35403 Phone: 205-348-0808 ❏ O-line / D-line: June 19 $25.00 Pre-registration deadline is June 1, 2010. KEY DEPOSIT $50.00 Only cash, money order or cashiers checks. *Key deposit for overnight campers only No Personal Checks will be accepted. Make check payable to: Nick Saban Football Camp LLC.