EmailMe Form - Camp Courageous

Scholar Name *

First Last

Birthdate *

MM / DD / YYYY

Scholar T-Shirt size: *

Gender *

Male

Female

Grade Entering for 23/24 School Year *

What School Does Your Child Attend? *

Student's School STATE ID? (This number is 7 digits and is NOT the same as the 6 digit Student ID. This number is used for student funding and testing purposes and can be released by School Secretary, PLC Coach, Guidance Counselor or can be located in Power School) *

Parent/Guardian 1- First & Last Name *

Relation to Child *

Permanent Address (Including City, State & Zip Code) *

Phone *

### - ### - ####

Phone Type

Email *

Parent/Guardian 2-First & Last Name

Relation to Child

Permanent Address

Phone

### - ### - ####

Phone Type

Email

Emergency #1 Contact Name *

Emergency #1 Contact Phone *

### - ### - ####

Emergency #2 Contact Name *

Emergency #2 Contact Phone *

### - ### - ####

Please list any allergies or dietary restrictions *

Please list any medical conditions we should be aware of *

Is there any special needs required for this scholar? *

Please list those authorized to pick-up your child. Those listed will need to show ID. (reply "N/A" if there is no one authorized) *

1
2
3

Choose which sport your child will be participating in (Please note that youth can participate in both Basketball/Cheer and Track): *

Core Programming is from 8am-5pm. We do offer Before-care programming starting 6:30am-8am. Will you be needing the Before-Care programming? *

Yes

No

Waviers

MBI PAL Youth Academy of Dreams/Legacy of Legends CDC Participation Agreement:
I give permission for my child to participate in the Summer/Extended Learning activities at Camp Outrageous. I reserve the
right to withdraw my child from participating in the program at any time. I give permission for my child’s school records to be accessed and
released to the center which best supports my child’s achievement in the program with the understanding that it will be confidential and will not be shared beyond the afterschool and programs. *

I Agree

I Do Not Agree

WAIVER/RELEASE FOR COMMUNICABLE DISEASES INCLUDING COVID-19
ASSUMPTION OF RISK / WAIVER OF LIABILITY / INDEMNIFICATION AGREEMENT:

In consideration of being allowed to participate on behalf of Memphis Bears PAL (MBI PAL)/ Legacy of Legends programs and
related events and activities, the undersigned acknowledges, appreciates, and agrees that:
1. Participation includes possible exposure to and illness from infectious diseases including but not limited to MRSA, influenza, and COVID-19. While particular rules and personal discipline may reduce this risk, the risk of
serious illness and death does exist; and,
2. I KNOWINGLY AND FREELY ASSUME ALL SUCH RISKS, both known and unknown, EVEN IF ARISING FROM THE NEGLIGENCE OF THE RELEASEES or others, and assume full responsibility for my participation;
and,
3. I willingly agree to comply with the stated and customary terms and conditions for participation as regards protection against infectious diseases. If, however, I observe and any unusual or significant hazard during my
presence or participation, I will remove myself from participation and bring such to the attention of the nearest official immediately; and,
4. I, for myself and on behalf of my heirs, assigns, personal representatives and next of kin, HEREBY RELEASE AND HOLD HARMLESS MSPAL, their officers, officials, agents, and/or employees, other participants,
sponsoring agencies, sponsors, advertisers, and if applicable, owners and lessors of premises used to conduct
the event (“RELEASEES”), WITH RESPECT TO ANY AND ALL ILLNESS, DISABILITY, DEATH, or loss or damage to person or property, WHETHER ARISING FROM THE NEGLIGENCE OF RELEASEES OR OTHERWISE, to the fullest extent permitted by law.
I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY
UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.

FOR PARTICIPANTS OF MINORITY AGE (UNDER AGE 18 AT THE TIME OF REGISTRATION)
This is to certify that I, as parent/guardian, with legal responsibility for this participant, have read and explained the provisions in this waiver/release to my child/ward including the risks of presence and participation and his/her
personal responsibilities for adhering to the rules and regulations for protection against communicable diseases.
Furthermore, my child/ward understands and accepts these risks and responsibilities. I for myself, my spouse, and child/ward do consent and agree to his/her release provided above for all the Releasees and myself, my spouse,
and child/ward do release and agree to indemnify and hold harmless the Releasees for any and all liabilities incident
to my minor child’s/ward’s presence or participation in these activities as provided above, EVEN IF ARISING FROM
THEIR NEGLIGENCE, to the fullest extent provided by law. *

I Agree

I Do Not Agree

MBI PAL/Legacy of Legends CDC MEDIA RELEASE FORM

RELEASE/AUTHORIZATION TO PUBLISH

Below is a legal release for MBI PAL/Legacy of Legends CDC to use your child participant’s name, and/or picture on the affiliated website and any media publications. Please read and carefully sign and return.

I/We as Participant (as previously defined above) hereby give MBI PAL/Legacy of Legends CDC, unrestricted rights to publish, distribute electronically and or/use of any still or motion pictures of Participant for use in editorial art, advertising, trade or any other lawful purpose. I, Participant, understand my likeness may be used in advertising and/or promotions. I hereby release and hold harmless MBI PAL/Legacy of Legends CDC, its successors, coaches, instructors, employees, agents, volunteers, heirs and assigns from any liability or claims of damage whatsoever in connection with said use of my likeness. I, Participant, waive any right to inspect and approve final use of any materials covered hereunder. Participant hereby waives any right to compensation for use of my likeness in media publication. Participant certifies that I am at least 18 years old or if a minor have included a signatory to this release my parent or legal guardian as Participant, whose name and signature appear below.

I have read and understand this release and certify that this information is true an accurate. *

I Agree

I Do Not Agree

Consent Form
Legacy of Legends CDC (LLCDC) will provide Total Well-Being Services to participants of the camp that will consist of referrals to clinical partners, as necessary, wrap around services and connection to natural community supports. By signing this consent, you agree to allow Legacy of Legends CDC to collect participant information to include, name, date of birth, demographic data (age, race, gender, ethnicity).
You also agree to allow LLCDC to disclose personal information collected regarding me or my dependent in CoactionNet (a database used to provide better coordination of services in our community). By signing this consent, you agree:
* I understand that I may end this consent at any time.
* I understand that there may have been information shared and services provided based on this consent when it was in effect. Ending this consent cannot change that.
* I understand that any notice to end this consent must be in writing. *

I Agree

I Do Not Agree

Signature

Clear

Single Line Text

Price *

$ Dollars