Waiver and Medical Release Form

Waiver and Medical Release Form
Please print and mail with payment and completed camp application to:
Championship Volleyball Camps of East Texas
P.O. Box 13027 - SFA Station
Nacogdoches, TX 75962

Camper Name: _____________________________________________

Please check camp you are attending:  Beginning Skills Camp   Individual Skills Camp Team Camp  
                                      Position Camp           Coaching clinic

Please answer the following questions about your health insurance:

Insurance Provider:_____________________________________________  


Subscriber Name:_____________________________________________ 


Subscriber Number:_____________________________________________


Group Number:_____________________________________________

As the parent and/or legal guardian of_____________________________________________ (name of camper), I hereby authorize the staff of Championship Volleyball Camps of East Texas, to act for me according to their best judgment in any emergency requiring medical attention. I assume the risk of accident or injuries from whatever cause in connection therewith, and release Championship Volleyball Camps of East Texas and their officers, agents and employees from any and all liability for any such accident or liability.
I HEREBY AUTHORIZE IN ADVANCE ANY NECESSARY MEDICAL TREATMENT REQUIRED BY THE ABOVE NAMED CHILD WHILE IN ATTENDANCE OF THIS CAMP. I ALSO ACKNOWLEDGE THAT I HAVE/WILL NOTIFY THE CAMP PERSONNEL OF ANY SPECIAL MEDICAL NEEDS OR INFORMATION REQUIRED BY THE ABOVE NAMED CHILD
Also, I understand that all rules and regulations for the camp will be enforced and any violation by my child will result in a collect call to me with a possible request to come and pick up my child with no refunds being given.



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Signature of Parent or Guardian          Date