2012 Maximum Velocity Track & Field Academy Registration Form

Mail registration form and payment to: MVTFA, Lisa H. Owens, 600 West Walnut Street, Danville, KY 40422

Name: _________________________________ Age: ________ E-mail: _________________________________ ____

Gender:______ Shirt Size: _______

School: _______________________________

Mailing Address: ______________________________________________________________________ City: _______________________________ State: _____________________ Zip: ____________

Home Phone: ___________________________ Preferred Events (select up to 3): ___HJ ___LJ ___TJ ___PV ___Shot Put

Emergency Phone: ___________________________

___Discus

___Hurdles

___Sprints

___Middle Distance

___Distance

Camper Status (check one): ___Overnight Camper-$400.00 ___Commuter Camper-$315.00 ___Commuter Coach/Parent-$200.00 Payment Plan (check one): ______ I am paying a NON-REFUNDABLE DEPOSIT ONLY-$100.00 (Balance Due No Later Than 5/30/12) ______ I am paying IN FULL (check or money order only) Authorization to Participate/Insurance Verification/Liability Release Medical Insurance Company: ____________________________________________________________ Policy #: _____________________ Group#: _________________ I.D. #: ____________________

I give my daughter/son/self ___________________________________________ permission to participate in the Maximum Velocity Track & Field Academy to be held at Centre College in Danville, KY on June 13-16, 2012. I have no knowledge of any physical impairment that would be affected by the above named campers participation in the Academy program. I hereby authorize the staff of MVTFA to act for me according to their best judgment in any emergency requiring medical attention. I give permission for my child/self to be treated by a physician and/or hospital should immediate attention be deemed necessary and recognize that any fees incurred will be my responsibility. I hereby waive and release Centre College, Jackie, Joyner Kersee, Sharrieffa Barksdale, and other volunteers or workers of the Academy of any and all liability from injury or illness sustained while participating in this Academy. I also understand that the Academy retains the right to use, for publicity and advertising purposes, photographs of campers taken at the Academy. Name of Parent/Guardian/Coach (please print): ___________________________ Date: ___________ Signature of Parent/Guardian/Coach: ______________________________________________________