Ignite Elite Combine_ by ghkgkyyt

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									                                                                                                                                       Print this registration form
                                                                                                                                       and mail prior to 3/22/2011

                                                               Bright House Sports Network
                                                                   Ignite Elite Combine,
                                                                      March 26th, 2011 8a-2p
                                                                  Presented by Big County Preps
                                                             SKYWAY Park, 3901 George Rd.
                                                           Tampa, FL 33634 (outdoor field turf)
                                                                  REGISTRATION FORM
                                                                            (Please Print)

                                                                                                   All Payments Must be made online.
Today’s date:                                     T Shirt Size: M L XL 2X 3X
                                                                                                   Pay Pal Transaction ID#
                                                                                                   (found on payment receipt)
                                                               ATHLETE INFORMATION
Participant’s last name:                              First:                      Middle:                                     (circle primary) (square secondary)
                                                                                                  JR           FR
                                                                                                   SO                       Off: QB / RB / WR / OL / TE
                                                                                                                              Def: DL / LB / DB / K
Height:                             Weight:                                  Birth Date:                                      Age:

Address:                                  City:                                                       State:                           ZIP Code:


HM PH: (        )                                      CELL PH: (       )                                       EMAIL (must have):

What college programs have made you a verbal offer:


                                                               SCHOOL INFORMATION
School:                                 Head Coach Contact PH:               Contact Coach EMAIL:
                                        (      )
Head Coach:

                                                                             County:                                          School PH:
School address:
                                                                             City:                                            (       )
                                                                             State:
                                                                             Zip Code:


                                                           INSURANCE INFORMATION
                                                      (Please attach a copy of your insurance card)

Name of Insured:                        Address (if different):



Is this athlete covered by insurance?       Yes         No

Please indicate primary insurance

Group no:                                                                           Policy no.:

relationship to insured:                      Self             Spouse           Child           Other


                                                               IN CASE OF EMERGENCY
Name of local friend or relative (not living at same address):       Relationship to Athlete:                    HM PH: (          )

                                                                                                                 Cell PH: (       )
The above information is true to the best of my knowledge. I also authorize Mega Sports Camps or insurance company to release any information
required to process my claims.


  Patient/Guardian signature                                                                                      Date
    Mail Registration Forms to:
    Big County Preps, LLC
    PO Box 1428, Valrico, FL 33594


      PO Box 1428, Valrico, FL                                 33595 | info@bigcountyprpes.com                                                bigcountypreps.com
                                                                                                                        Print this registration form
                                                                                                                        and mail prior to 3/22/2011


                                                       RELEASE OF LIABILITY


I hereby authorize the Directors of Big County Preps, LLC and Mega Sports Camps, LLC to act for me according to their best judgment in any
emergency requiring medical attention.

I hereby waive and release the Big County Preps, LLC and Mega Sports Camps, LLC and all Directors, Officers, and
Instructors from liability arising from my child’s participation at the Camp and I know of no mental or physical
problems which might affect my child’s ability to safely participate in this Camp. I will be responsible for any
medical or other charges in connection with my child’s attendance at Camp. Costs for treatment of injuries or
hospitalization for illness or injuries incurred during the camp will be the responsibility of the parent or guardian
of the camp participant.

Any insurance carried by the parent or guardian may be used to defray such medical and hospital costs. All
campers are covered by a group accidental insurance policy by the Mega Sports Camps, LLC.

Student Athlete Name:
Student Athlete School:


______________________________________________________________________________________________________
Parent / Guardian Signature                                                                   Date




                                                        MEDIA RELEASE FORM

I, the undersigned, do hereby consent and agree that Big County Preps/Bright House Sports Network, its employees, or agents have the right
to take photographs, videotape, or digital recordings of my child. The use these in any and all media, now or hereafter known, and
exclusively for the purpose of promotional and educational reasons to utilize in publications, posters, brochures, website and newsletters; for
Big County Preps publications or those affiliated and/or participating with Big County Preps/Bright House Sports Network. I further consent
that my child’s name and identity may be revealed therein or by descriptive text or commentary.
I do hereby release to Big County Preps/Bright House Sports Network, its agents, and employees all rights to exhibit this work in print and
electronic form publicly or privately and to market and sell copies. I waive any rights, claims, or interest I may have to control the use of my
identity or likeness in whatever media used.
I understand that there will be no financial or other remuneration for recording me, either for initial or subsequent transmission or playback.

     □ ISports Network publications or those affiliatedinterviewed, photographed Big videotaped for use inHouseCounty Preps/Bright use by
          give my permission for my child to be
                                                         and/or participating with
                                                                                   or
                                                                                      County Preps/Bright
                                                                                                           Big
                                                                                                                Sports Network for
                                                                                                                                   House

          general news media for print or broadcast and national prep athletics publications, websites or broadcast.

     □ IHouse NOT give my permission for those affiliated and/or participating with Big County Preps/BrightinHouseCounty Preps/Bright
         DO
              Sports Network publications or
                                             my child to be interviews, photographed or videotaped for use    Big
                                                                                                                   Sports Network for
          use by general news media for print or broadcast and national prep athletics publications, websites or broadcast.



Student Athlete’s Name:                                                            Date:

Parent/ Guardian Contact Phone:
Student Athlete’s School:


Parent/ Guardian Name (please print):


Parent/ Guardian Signature:


Please sign / date and attach with registration form.

  PO Box 1428, Valrico, FL                            33595 | info@bigcountyprpes.com                                          bigcountypreps.com
                                                                                                 Print this registration form
                                                                                                 and mail prior to 3/22/2011

                                           CONFIDENTIALITY AGREEMENT

It is understood and agreed to that the Discloser and the Recipient would like to exchange certain information
that may be considered confidential. To ensure the protection of such information and in consideration of the
agreement to exchange said information, the parties agree as follows:


     □ Yes, I allow Big County Preps, to share my student athlete’s name, mailing address, contact phone,
           school and athletic information, core GPA and Standardize test score (ACT/SAT), for collegiate recruiting
           purposes.


     □ I DO NOT allow Big County Preps, to share my student athlete’s name, mailing address, contact phone,
           school and athletic information, core GPA and Standardize test score (ACT/SAT), for collegiate recruiting
           purposes.



 X                                    X
 Parent/Gaurdian signature            Parent/Gaurdian name (please print)


Recipient shall use the Confidential Information only for the purpose of evaluating and marketing student
athletes.

Recipient shall limit disclosure of Confidential Information within its own organization to its directors, officers,
partners, members and/or employees having a need to know and shall not disclose Confidential Information to
any third party (whether an individual, corporation, or other entity) without the prior written consent of Discloser.

This Agreement imposes no obligation upon Recipient with respect to any Confidential Information (a) that was in
Recipient’s possession before receipt from Discloser; (b) is or becomes a matter of public knowledge through no
fault of Recipient; (c) is rightfully received by Recipient from a third party not owing a duty of confidentiality to
the Discloser; (d) is disclosed without a duty of confidentiality to a third party by, or with the authorization of,
Discloser; or (e) is independently developed by Recipient.

Neither party has an obligation under this Agreement to purchase any service, goods, or intangibles from the
other party. Discloser may, at its sole discretion, using its own information, offer such products and/or services
for sale and modify them or discontinue sale at any time. Furthermore, both parties acknowledge and agree that
the exchange of information under this Agreement shall not commit or bind either party to any present or future
contractual relationship (except as specifically stated herein), nor shall the exchange of information be construed
as an inducement to act or not to act in any given manner.

Neither party shall be liable to the other in any manner whatsoever for any decisions, obligations, costs or
expenses incurred, changes in business practices, plans, organization, products, services, or otherwise, based on
either party’s decision to use or rely on any information exchanged under this Agreement. If there is a breach or
threatened breach of any provision of this Agreement, it is agreed and understood that Discloser shall have no
adequate remedy in money or other damages and accordingly shall be entitled to injunctive relief; provided
however, no specification in this Agreement of any particular remedy shall be construed as a waiver or prohibition
of any other remedies in the event of a breach or threatened breach of this Agreement.

WHEREFORE, the parties acknowledge that they have read and understand this Agreement and voluntarily
accept the duties and obligations set forth herein.

Recipient of Confidential Information:
Big County Preps LLC




  PO Box 1428, Valrico, FL                        33595 | info@bigcountyprpes.com                       bigcountypreps.com
                                                                                                               Print this registration form
                                                                                                               and mail prior to 3/22/2011

                                                 Ignite Elite Football Combine
                                                         CHECK LIST
                                                   Check in time is 7:00a
                      K E E P T H I S F O R M – DO NOT MAIL

     Make sure you do this


 □ Payment made online (bigcountypreps.com)
 □ Mail the following:
 □ Completed registration form (once registration information is received, an email will be sent to the address provided with the
      participant’s confirming paperwork was received). An email address must be submitted on the registration form. If you do
      not have email access, please ask your coach if your confirmation number can be sent to his/her email address.

 □ Copy of insurance card
 □ Release of Liability/Media Release Form
 □ Confidentiality Agreement form


      Day of Event

 □ Identification (school ID, driver’s license or state ID card)
 □ Cleats and tennis shoes
 □ Duffle bag with name tag or labeled
 □ QBs, bring own labeled football
 □ Any other athletic gear
 □ Water and/or sports drink and snack
 □ Personal spending money
                                                                   BHSN Ignite Elite Combine Address


                                                                   Skyway Park
                                                                   3901 George Road
                                                                   Tampa, FL 33634
                                                                            -




PO Box 1428, Valrico, FL                         33595 | info@bigcountyprpes.com                                      bigcountypreps.com

								
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