PARENT/PARTICIPANT PERMISSION
AND
RELEASE OF LIABILITY
Child/Participant Name: _____________________
Date of Birth: _____________
Social Security # ________________________
Grade: ____________________________
Address: _______________________________
City: __________________
State: _______ Zip: ________________________________
Home Phone: ( ) _________________ Work Phone: ( ) __________
Cell ()______________________
Release of Liability
The undersigned hereby agree that I, my assignees, heirs, distributes, guardians and legal representatives will not make a claim against, sue, or attach the property of The Phelps School and shall indemnify, hold free and harmless, assume liability for, and defend its agents, independent contractor, servants, employees, officers, members and directors from any and all liability for personal injury or damage resulting from the negligence or other acts, howsoever caused or property damage and costs and expenses including but not limited to, attorney's fees, reasonable investigative and discovery costs, court costs, and all other sums for any claim or action founded thereon, arising or alleged to have arisen out of _______________________(child's name/Participant) use of the real or personal property belonging to or used by Agent while Minor is in the presence of Agent.
By my signature below, I further release The Phelps School from all actions claims or demands that I, my assignees, heirs, distribute, guardians and legal representatives now have or may hereafter have of injury or death resulting from the named party’s participation in The Phelps School Summer programs.
Parent/Participant__________________________________ Date: _________
Signed __________________________________________ Date: __________
Parent___________________________________________ Date: _________
Signed __________________________________________ Date: __________
ADDENDUM TO PARENT PERMISSION AND RELEASE OF LIABILITY
Home Phone: ___________________ Work: ____________________
Other phone number: _______________________________________
Legal Guardian: __________________________Phone: _______________
Other Emergency Contact: __________________Phone: _______________
Family Doctor: ___________________________Phone: _______________
Insurance Co.: ______________________________
If None Please Check: [___]
Insurance Policy Name and #: ____________________________________
Known Medical Conditions: _____________________________________
Medications? ________________________________________________
Allergies? ___________________________________________________
Last Tetanus Immunization? _______________________________________
Will You Allow Blood Transfusions? (Check your response) Yes [____] No [____]
Other Comments: ________________________________________________
Parent__________________________________________Date: __________
Signed__________________________________________Date: __________
Parent__________________________________________ Date: __________
*The Phelps School does not provide onsite trainers or any other medical staff. The Phelps School only has the ability to call 911 in case of emergency.
The Phelps School Summer Programs Registration Form
Participants Name: __________________________________
Date: ___________________________________________
Address: _________________________________________
City: ____________ State: ______ Zip: _______
Age: ____ Grade: ______ Gender: _________
Phone number: ______________
Sports Played in the past: ____________________________
Skill Level in those sports (circle one): Beginner, intermediate, advanced
Program Registering For: _____________________________________
Date of Program: ___________________________________________
Cost of Program: ____________________________________________
Extended (AM) days registering for: ____________
Extended (PM) days registering for: _____________
Total amount of program and extended (AM/PM) if needed ____________
Refund Policy
The Phelps School Summer Programs has a no-refund policy. However, if you are unable to attend the program you registered for, you may apply your registration to a future program this year or next year by calling 610-644-1754 ext. 1600.
The Phelps School Summer Programs does not pro-rate for missed camp days.
Method of Payment:
Check (enter check number and amount) Check number______ Amount $ ______
*Make check out to “The Phelps School”
Credit Card Number: ___________________________________
Expiration Date: _______
Three digits Security Number on back of card: _________
Name on card: _____________________________________
Billing Address of card holder __________________________
_________________________________________________
Registration/Waiver: Please make sure that you fill out completely the registration form as well as the liability and release form and mail them in with payment to:
The Phelps School
Attn: Summer Camps
583 Sugartown Road
Malvern, PA 19355