REQUIRED INFORMATION:

PLAYER NAME_______________________

STREETADDRESS____________________________

City ______________ State ________ Zip ______

Phone (____)_______________________

Parents Name_____________________________

Neccessary information for proper placement

Circle Grade this fall - - - - 9 - 10 - 11 - 12

Age_________ HT___________ WT________

(Circle One Position Only)

QB - FB - HB/SL - WO - OC - OG - OT - TE

School____________________Coaches Name_________________

Roommate Preference_______________________________

2ND Roommate Preference____________________________

Circle session of choice

Session I - June11-14th , 2010

Session II - June 18-21st, 2010

Session III - June 24-27th, 2010

DO NOT WRITE BELOW THIS LINE

DEPOSIT ---------- BALANCE

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ACKNOWLEDGMENT MEDICAL CONSENT FORM

We the parents ( or Guardian) of_________________________

(Print Name of athlete)do hereby acknowledge that we have been advised, cautioned, and warned by the proper administrative and coaching personnel Indiana Option Camps, Inc.,that our child may suffer an injury, by participation in sports. Not withstanding such warnings, and withn full knowledge and understanding of the risk of injury, the above named student has our consent to participate in this camp. In the event that an emergency arises during the camp, an effort will be made to contact the parents or guardians as soon as possible. If the parents or guardians cannot be reached, permission is hereby granted to the attending physician to proceed with any emergency medical or minor surgical treatments, X-ray examinations and immunizations for this athlete. In the event of serious illness, significant injury or the need for major surgery, the attending physician will attempt to contact the parents or relatives. If the physician is not able to communicate with the parents or relatives, the treatment necessary for the best interest of this athlete may be given. Indiana Option Staff has authorization of treatment in the absence of parental permission. Permission is also granted to the coach or athletic trainer to provide the needed emergency treatment to the athlete prior to admission to the medical facilities and to sign all neccesary documents on the parents behalf.

.________________________________/ ________

Parent or Guardian Signature - - - - - Date

Phone ( ) ____________

Cell Phone ( ) _________________

_________________________________ /_______

Student Signature - - - - - - - - - - - - - - - - -Date

Applicant's Insurance Co.__________________________

Policy Number_______________________________

List Any restrictions/medical problems