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MEDICAL INSURANCE RELEASE

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MEDICAL INSURANCE RELEASE Powered By Docstoc
					                   INSURANCE / PARENT CONSENT FORM
In consideration of the acceptance of my participation and use of the below-named facility,
I do hereby, for my heirs, executors and administrators, waive release and forever
discharge any and all rights and claims for damages that I may have, or which may
hereafter accrue, against Darin Spence Basketball Camps and New Mexico State
University Regents, Officers, Staff Employees, Faculty and Students, collectively referred
to as “University” and to indemnify and save harmless the UNIVERSITY against any and
all claims for loss, injury or damage to persons or property, arising out of the activities
conducted by the PERMITTEE, its agents, members or guests.

I have read the above statement. I understand it, and my signature(s) confirm its full
acceptance. I attest and verify that I have full knowledge of the risk involved in this event
and am physically fit and sufficiently trained to participate in this event and use of camp
facilities for the 2010 Darin Spence High School Team Basketball Camp on June 18th – 20th.



Applicant’s Signature:___________________________________________ Date__________


Parent/Guardian’s Signature:_____________________________________ Date__________


Emergency Contact:____________________________________________________________

             Phone:____________________________________________________________


Health Insurance Carrier:_______________________________________________________

                          ________________________________________________________


Group or Policy Number:_______________________________________________________

				
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