Name:    

Address: 

City:       State: Zip:

Phone :  

School :  Grade (Next Fall):

Height: Weight: 40:

Positions: OFF DEF


     The undersigned, as parent or guardian of the child named above, desires that my child participate in the football camp offered by Wake Forest University; and by execution of this release I agree that all requirements, directions and standards set by the coaching staff and personnel, use of any equipment under the supervision of the coaching staff and personnel shall be deemed to have been accomplished for the benefit of my child.
     In consideration of Wake Forest University’s efforts on my child’s behalf, I do hereby voluntarily assume all risk of accident, injury, damage and/or loss to my child or my child’s property which may arise out of my child’s participation in the football camp, hereby intending to release and discharge the state of North Carolina, Wake Forest University, the director, personnel involved or otherwise which may result from participation in the football camp.
     Authorization: I authorize and request the Wake Forest University Student Health Services or Baptist Hospital to administer all requested and/or indicated outpatient medical and surgical services, and when necessary provide tetanus immunization, perform emergency procedures, or refer to other duly licensed medical personnel for necessary emergency treatment when indicated, including transfer to outside hospitals.

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Signature of parent/guardian if participant is under legal age (18)

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Date                                            Phone Number

Make check or money order payable to Jim Grobe Football Camp.
Mail registration form to Jim Grobe Football Camp, P.O. Box 7268, Winston-Salem, NC 27109