Inaugural McClure Middle Dodgeball Tournament

February 26, 2015

4:00 pm 7:00 pm
Student Players Name:
Team Name:

Team Captain:

Grade:

Homeroom teacher:

Student Parents Name:

Parents Cell Number:
Cost is $5 per registrant. Checks should be made payable to SMMS PTSA. Please place registration form and fee in plain
envelope and leave with your homeroom teacher with Dodgeball written on outside.
Having been made aware of the activities the registrant will be doing, I hereby consent to the registrants
participation in the dodgeball tournament at McClure Middle School. I voluntarily release and discharge
SMMS or SMMS PTSA from any and all liability, claims, actions, or rights of action which are in anyway
related to the registrants participation in the tournament. I agree to indemnify and hold SMMS or SMMS
PTSA harmless from any and all costs or damages, including attorney fees, incurred in connection with the
registrants participation in the tournament. I further agree not to sue, assert or otherwise maintain any
claim or cause of action against SMMS or SMMS PTSA arising from the registrants participation.
In case of emergency, I understand every effort will be made to contact parents or guardians. However, if
parents or guardians cannot be reached, I hereby give SMMS PTSA or SMMS permission to act on my behalf
in seeking and administering medical treatment in the event that such treatment is deemed necessary. I
release SMMS and SMMS PTSA from liability in acting on my behalf in this regard and rendering such
medical treatment.
Signature
Print name:
Emergency contact name:
Day phone:

PTSA Use Only: Cash Check #___________ Completed By: _______________