North Allegheny Cheerleaders

Mini Camp Application

I attend

School

E-mail Address:

Cheerleader’s Last Name

First Name

Nickname

Address

City

Zip Code

Phone (H)

Date of Birth (Month/Day/Yr)

Age

Grade

Cell Phone

Place me with one friend:

Please circle T-Shirt Size: Child S(6-8) M(10-12)

L(14-16) or Adult S M

L XL

(shirts will be available for sizing at Registration)

Father’s Name

Mother’s Name

By my signature(s), I (we) give approval for the above child to participate in any and all activities of the Cheerleading Mini Camp. I (we)

assume all risks and hazards incidental to the conduct of the activities. I (we) agree to release, absolve, indemnify, and hold harmless the

North Allegheny Cheerleaders and NA Cheerleading Boosters Association, its officers, directors, coaches, and supervisors in the case of injury

to our child during these activities.

Medical Authorization

Allergies or Medical History we should be aware of (include Medications)

To whom it may concern: If neither parent can be contacted in the case of injury or illness, I hereby authorize representatives of the NA

Cheerleading Boosters Association to act as my agent to secure emergency medical treatment for

,

a minor child for whom I am responsible, at the nearest hospital, when in the opinion of the representatives, such emergency medical

treatment is deemed appropriate during the time when my child is engaged in the camp activity. I hereby agree to hold the NA Cheerleading

Association and its representatives harmless for exercising its judgment in authorizing such emergency treatment and said representatives are

specifically authorized to sign any required medical emergency hospital treatment form on my behalf.

Parent/Guardian Signature

Date

Family Physician

Phone Number

Nearest Relative/Neighbor

Phone Number

Refunds may be given on an individual basis minus cost incurred.

CAMP USE: REGISTRATION FEE CHECK #

CASH