Junior Wildcat Speed & Strength Summer School

Junior Wildcat Speed & Strength Summer School

Tuesdays & Thursdays • 4 Time Slots Available
Parent/Guardian Name

First NameLast Name
Parent/Guardian Phone Number
Format: (000) 000-0000.
Parent/Guardian Email
example@example.com
Student Name

First NameLast Name
Student Date of Birth

MonthDayYear
Date
Student Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Media Release (Do you give AMHS permission to share pictures of your student on AMHS social media/marketing?)
PLEASE NOTE: For the time slots below, sessions 1 and 2 (12:00 pm and 12:30 pm) are for 5th/6th graders. Sessions 3 and 4 (1:00 pm and 1:30 pm) are for 7th/8th graders. Please choose accordingly.
Grade/Time Slot

Payment Information

$115.00

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Total

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Liability and Medical Waiver

Please read carefully and acknowledge the terms below.
Consent Agreement
I grant permission for my child to participate in this AMHS class. This class will take place under the guidance and direction of school employees and/or volunteers from Archbishop Murphy High School.

As parent and/or guardian, I remain legally responsible for any personal actions taken by the above named minor participant.

I agree on behalf of myself, my child named herein, or our heirs, successors and assigns, to hold harmless and defend Archbishop Murphy High School, its officers, directors and agents, and the Corporation of the Catholic Archbishop of Seattle, chaperones, or representatives associated with the event, from connection with my child attending the event or in connection with any illness or injury or cost of medical treatment in connection therewith, and I agree to compensate the school, its officers, directors and agents, and the Corporation of the Catholic Archbishop of Seattle, chaperones or representatives associated with the event for reasonable attorney's fees and expenses arising therewith.
Parent/Guardian Signature
Emergency Information
Emergency Contact #1 Name

First NameLast Name
Emergency Contact #1 Phone Number
Format: (000) 000-0000.
Emergency Contact #2 Name

First NameLast Name
Emergency Contact #2 Phone Number
Format: (000) 000-0000.
Physician Name
Physician Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Physician Office Number
Format: (000) 000-0000.
Preferred Hospital
Insurance Company
Policy Number
Policy Holder
Does your child have any health conditions we should be aware of? If YES, please indicate
Other Allergies (please list type of allergy and reaction whether mild or severe)
Activities in which your child should NOT participate or additional comments
Medical Release
I declare that I am the parent/guardian of child is injured or should require medical attention, I hereby request you to contact our physician. In the event that the doctor cannot be reached, I hereby authorize the necessary medical treatment for my child. I further acknowledge that I will be responsible for any medical or hospital fees or costs associated with my child's treatment. If possible, confirmation of this authorization should be made prior to treatment by calling me at the listed phone number(s).
Parent/Guardian Name

First NameLast Name
Parent/Guardian Signature
Today's Date

MonthDayYear
Date
12911 39th Avenue SE Everett, WA 98208-6159
Ph (425)379.6363 • Fax (425) 385-2875 • www.am-bs.org
Northsound Association for Catholic Education
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Junior Wildcat Speed & Strength Summer School

Payment Information*

Credit Card

Liability and Medical Waiver

Consent Agreement

Emergency Information

Medical Release

Payment Information