Name__________________________ School _______________________

Home Address _________________________________________________

City ___________________________________ Zip Code ______________

Phone (       ) ______________________ e-mail ______________________

Grade 2009-10 ________________ Height ___________ Weight _________

Parent/Guardian _______________________________________________

Please Mail $60.00 Check (Make Checks Payable to “Fullcourt Press”) and Completed Form to:

Dinos Trigonis, 3122 Theresa Street #1, Long Beach CA  90814

HEALTH AND BEHAVIOR GUIDELINES AND WAIVER OF LIABILITY

HEALTH INSURANCE CO. ______________________________________________________

Policy No. _____________________________________ Group No. _____________________

I understand that any Fullcourt Press Fall Showcase participant who does not abide by the rules, regulations and policies established by the Fullcourt Press Fall Showcase (FPFS) is subject to dismissal without reimbursement or recourse and I hereby waive and release the FPFS and Long Beach Poly High School (LBPHS) from any and all liability for any injury or illnesses while participating in the camp.  I hereby authorize the directors of the FPFS and LBPHS to act according to their best judgment in any emergency if I cannot be contacted.  I understand that each camp participant is required to have their own medical and accident insurance.  I also understand that the FPFS retains the rights to use for publicity and advertisements purposes, photographs of camp participants.

SIGNATURE OF PARENT OR GUARDIAN

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