*************CHEER CAMP*************
Registration has begun for the 2014
SMHS Warrior Cheerleaders Summer Cheer Camp
For Girls 5-14 Years Old
When: July 28th-August 1st
Time: 9:00am - 1:00pm
Where: Saint Michael High School
6301 Campus Drive
Fredericksburg, VA 22407
540-548-8748
$35 for pre-registered campers
$40 at the door
Camp includes:
Cheer routines instructed by the
2013-14 Delaney Athletic Conference
First Place Champions
SMHS Warrior Cheerleaders,
Lunch, swimming and camp t-shirt
-----------------------------------------------------------------------------------------------------------Name ______________________________ Age _____
Address__________________________ City___________________ State_____
Home Phone______________________ Cell Phone___________________
Parent ___________________________
Emergency Contact Name_______________________ Phone_________________
Allergies ________________________
T-Shirt Size (circle one) YS YM YL
AS AM AL
(see reverse side)
Please provide the following information for your child:
Allergies (medication, food, bee sting, poison ivy, etc)
_________________________________________________________________
_________________________________________________________________
Please describe the nature of the reaction (rash, hives, difficulty breading, etc
_________________________________________________________________
_________________________________________________________________
Injury history (eg, recent sprains, fractures)
_________________________________________________________________
_________________________________________________________________
Medical conditions (eg. Asthma, diabetes, cardiac disorders, seizure disorders)
_________________________________________________________________
_________________________________________________________________
Medications currently taking:
_________________________________________________________________
_________________________________________________________________
Date of last tetanus shot (month/ year)
_________________________________________________________________
RELEASE & CONSENT AGREEMENT
Saint Michael the Archangel Camp is to be held at the facilities of Saint Michael High School. Please read the
following agreement carefully before signing. Although camp participation is encouraged, it is encouraged only if
health and safety are considered.
CERTIFICATION OF PHYISICAL FITNESS TO PARTICIPATE:
1. I understand that by participating in any sport, including SMHS Cheer Camps, there is a risk of injury,
including but not limited to serious permanent injury, paralysis, and death. To minimize the risk of injury, I
agree to tell my child to obey all safety rules and to report fully any problems related to his/her physical
condition to the summer camp coaches and assistants as soon as the problem begins.
2. By signing below I certify the following:
-That my child is not currently under the care of a physician for an injury or illness that would prevent
his/her safe participation in the summer camp;
-That my child is not currently being treated for or recovering from an orthopedic injury that would prevent
his/her safe participation in the summer camp;
-That my child has no history of fainting or other problems related to strenuous exercise; and that my
child is in good health and there is no reason he or she cannot safely participate in strenuous physically
activity.
Parent/guardian signature ___________________________ Date ________________________
Consents:
1. By my signature below, I hereby give permission for Saint Michael H S and its employees and agents to
obtain medical treatment for my child, _____________ in the event of accident or illness during his/her
presence at the camp.
2. By my signature below, I herby give consent to have my child be photographed or videotaped during
camp activities, and I agree that the images so obtained may be used for educational and publication
purposes by Saint Michael H. S. camps.
Parent/guardian signature ___________________________ Date ________________________
Release:
1. In consideration for accepting my child into Saint Michael H. S. Camp, I do hereby agree that I am
responsible for all cost associated with any injury or loss that may be sustained by my child as a result of
his or her participation at the camp. I also certify that I have Insurance, which provides adequate
coverage for injuries or illness my child may sustain while participating in Saint Michael H. S. camps.
2. By my signature below, I also agree to release and promise not to sue the Saint Michael H. S. or their
employees or agents, for any damages, loss injury, or death arising from my child’s participation in Saint
Michael H. S camps, unless such damages, loss injury or death are caused by the gross negligence or
intentional gross misconduct of such employee or agents.
Parent/guardian signature ___________________________ Date ________________________