Name of Participant *

First Name

Last Name

Date of birth

MM

DD

YYYY

Start Date

MM

DD

YYYY

Contact Information for Participant

Enter parent name

First Name

Last Name

Address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Home phone

(###)

###

####

Cell phone or best number to be reached

(###)

###

####

First emergency contact

First Name

Last Name

Second emergency contact

First Name

Last Name

Waiver of Participant by parent or self *

In consideration of your accepting my or my child’s registration and entry, I hereby for myself, my child, my heirs, executors and administrators, waive and release any and all rights and claims for damages I or my child may have against The Town of Westport,The Field House, Growing Tree Yoga,LLC, or Sara Holland; and its representatives, successors and assigns, for any and all injuries suffered by myself or my child at the activity sponsored by these groups. I understand there is inherent risk associated with the(se) activity(ies) and authorize emergency medical treatment and transportation in my absence. If any of the above participants are minors, I certify by my signature that I am the custodial parent or guardian; or I have the expressed authorization of the custodial parent, or guardian to enroll said participant(s) in the specified activities listed.

I agree

I do not agree

Sara Holland Sports, Compass Sports Academy, LLC, has my permission to use my or my child’s photograph publicly to promote the camps and clinics. I also understand that no royalty, fee or other compensation shall become payable to me by reason of such use.

Yes

No