SPORTSZONE INDIVIDUAL REGISTRATION/WAIVER FORM
2011 DAY CAMPS

FULL  DAY ______   HALF DAY______       BEFORE CARE ______    AFTER CARE ______

DAILY ____    Monday____   Tuesday ____   Wednesday____    Thursday____    Friday____

PLEASE CIRCLE  WEEK(S) ATTENDING:   February 21-25 June 27 – July1 July 11-15 July 18-22

July 25 -29 August 1-5 August 8-12 August 15-19

Name________________________________________________________________________________

Address______________________________________________________________________________

City, State, Zip  _______________________________________________________________________

D.O.B.______________ GRADE_______ PLEASE CHECK ONE: FEMALE ________ MALE __________

I/we realize that for my/our child, or for myself, that participation in the active, physical sport that I/he/she am/is undertaking

At the SportsZone, can result in injuries during participation. I/we have sought the opinion of my/our child's pediatrician/

physician and he/she concurs that the participant is fully capable of safely participating in this activity. I/we understand that

it is my/our responsibility in caring for the participant(s) listed above and I/we are confident that he/she is fully capable of

engaging in this activity. I/we further agree to hold harmless the SportsZone Corporation from any and all legal

and financial liability connected with providing facilities for the purpose of participating in athletic and related activities.

I/we, our heirs, executors, administrators and assigns waive, release and forever discharge the SportsZone Corporation,

its directors, employees, any and all related parties from all rights and claims for damages, injury or loss

of person or property which may be sustained or occur before/during/or after participation on the premises of the

SportsZone whether or not due to negligence. I/we take full responsibility for accidents or injury to, or caused by,

my child or myself during, participation, or otherwise, while on the SportsZone premises. I/we hereby certify that I/we

have medical insurance to cover injury to my child or myself. In the event of injury or illness, the SportsZone

has my permission to seek any emergency medical treatment deemed necessary for me/or my child.

____________________________________________________________________________________
Participant's Signature
____________________________________________________________________________________
Signature of Parent/Guardian (If Participant is under 18 years old)

Phone: H____________________________________ W _____________________________________

Cell_________________________________  E-mail_________________________________________

Insurance Co.________________________________________________________________________

Name of Policy Holder_________________________________________________________________

Policy No.___________________________________________________________________________

PLEASE MAKE CHECK PAYABLE TO: SPORTSZONE CORPORATION
AND SUBMIT ALONG WITH THIS FORM TO: 7 'A' STREET, DERRY, NH 03038

FOR OFFICE USE ONLY:

Date __________  Amount___________  Check #__________ or Cash ________  By _____________