Form

If you would like any more info, you can contact us at   lcgfp@hotmail.com Messiah Pitching Clinic Form 2002 Falcon Softball Pitching Clinic (Please Print) Name :   ___________________________________ Address :   ___________________________________ City :   ___________________________________ State :   ___________________________________ Zip Code :   ___________________________________ Age :   ___________________________________ Grade :   ___________________________________ Name of Parent/Guardian :   ___________________________________ Phone :   ___________________________________ Work Phone :   ___________________________________ High School :   ___________________________________ Coach :   ___________________________________ Position(s) :   ___________________________________ Insurance Carrier of Athlete :   ___________________________________ The student named above has my permission to participate in the designated Messiah College one day clinic. I understand that clinic participation may involve significant physical activity which could result in injury. I certify that the child is in good physical condition and is fully able to participate. I assume all risk incident to the child's participation and release Messiah College, its employees, agents, officers, and volunteers from all liability, claims, expenses, and actions which may arise from injury or harm to the child as a result of clinic participation. In the event of a medical emergency, I authorize Messiah College to designate a physician or hospital or emergency personnel to provide medical care (including hospitalization, if necessary) to the child, and release Messiah College from any liability for injury or harm to the child which may result from this medical care. I understand that responsibility for payment for such medical care will be mine and certify that the child is covered by adequate medical insurance. Signature of Parent/Guardian :   ___________________________________ Date :   ___________________________________ Please include any significant history :   ___________________________________   ___________________________________   ___________________________________   ___________________________________   ___________________________________   ___________________________________

Please return with your deposit of $20.00 by January 7, 2002. Send your deposit to: Messiah College Softball One College Ave Grantham, PA 17027