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Camp Application

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For more information contact : CSM Michel Brondum, Jr. 3308 Angelique Dr, Violet, La 70092

 Telephone  504-682-7597 or 504-343-7597

Louisiana Junior Shooting Camp

July 16 July 20, 2003

1. Name:________________________________________ Date of Birth _____/_____/_______

                      Last                    First                    Middle

Address: ____________________________________________________________________

                       Number,   Street,   City,   State,   Zip

Telephone: (______ ) _______________________ School Year: ___________

A/C

Male ___________ Female ___________

Check Shirt Size: Large ___________ X Large ___________

2. Please list the name, phone number and address of your current coach:

Coach's Name: _______________________________ Phone No.: ( ) _____________

Address: ____________________________________________________________________

What team or organization does he or she coach, if any? _______________________________

3. Do you have a shooter's diary? Yes _______ No ________

4. Do you hold a State Club, NRA or USA Shooting membership? Yes _______ No ________

If yes, what Club or Clubs? ______________________________________________________

5. Discuss the type and extent of training & coaching you have received; what effect does it have on

your shooting?

_____________________________________________________________________________

_____________________________________________________________________________

6. Parental Permission and Athlete Code - The following statements must be read and signed by

the applicant and his/her parent or legal guardian:

I, _____________________________________________ , the parent or legal guardian of

______________________________ hereby give permission for my child to participate in the

2003 LOUISIANA JUNIOR SHOOTING CAMP applied for through this application.

It is understood that any athlete participating in the 2003 LOUISIANA JUNIOR SHOOTING CAMP will:

1. Participate fully in all activities;

2. Exhibit good behavior at all times;

3. Fully cooperate with the LA Shooting Camp staff; and,

4.  Comply with all camp and 2003 LOUISIANA JUNIOR SHOOTING CAMP Program regulations.

It is further understood that any breech of this Code may be cause for immediate and permanent expulsion from the 2003 LOUISIANA JUNIOR SHOOTING CAMP Program.

___________________________ __________________________________________

                 Date                                             Signature of Athlete

7. Parent or Guardian Name(s) and Address (es):

_____________________________________________________________________________

Name Address City/State/Zip

(______)_________________ ______________________________________

Home Telephone No. Relationship to Camper

Name of Business: _____________________________________________________________

Address ___________________________________ /_________________________________

                            No. & Street                                                  City/State/Zip

Business Telephone No. ( ________)__________________________________________________

Emergency Contact ___________________________ Telephone No. (_____ ) ___________

- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

Parent or Guardian Name (s) and Address (es):

_____________________________________________________________________________

Name Address City/State/Zip

_(______)_________________ ______________________________________

Home Telephone No. Relationship to Camper

Name of Business: _____________________________________________________________

Address: _____________________________/________________________________________

No. & Street City/State/Zip

Business Telephone No. ( )___________________________________________________

Emergency Contact _____________________________ Telephone No. ( ) ___________

 

PARENTS AUTHORIZATION

This health history is correct so far as I know, and the person herein described has permission to engage in all prescribed activities, except as noted by the undersigned and the physician. In the event I cannot be reached in an emergency, I hereby give permission to the physician selected by the adult leader in charge to hospitalize, secure proper anesthesia, or to order injections or surgery for my son or daughter.

_________________________________________ ______________________________

Signature of Parent or Guardian Date

The information provided is correct to the best of my knowledge.

_________________________________________ ______________________________

Signature of Applicant Date

LIABILITY/MEDICAL RELEASE

If I am injured or suffer any illness or disease while residing at, and participating in the programs of the 2003 LOUISIANA JUNIOR SHOOTING CAMP, and its sponsor (s), except as may be caused by the grossly negligence or reckless conduct of the 2003 LOUISIANA JUNIOR SHOOTING CAMP, and its sponsor (s), or its employees, I and my parent(s) or guardian (s) waive any legal claim against the 2003 LOUISIANA JUNIOR SHOOTING CAMP and its sponsor (s), Venture Crew 935, their agents, servants and employees.

I give consent for the 2003 LOUISIANA JUNIOR SHOOTING CAMP and its sponsor (s) to provide medical attention, transportation, and/or emergency medical services, as warranted by the circumstances.

I represent that I am in good physical condition and I am not aware of any disease or injury that would be aggravated or result in my being incapacitated or injured during any program participation.

I further understand and agree to abide by the General Rules of Conduct prescribed for guest (s) of the 2003 LOUISIANA JUNIOR SHOOTING CAMP and its sponsor (s), and that any violation may result in a denial of privileges and forfeiture of all fees paid.

I HAVE READ THIS RELEASE. I UNDERSTAND THAT IT AFFECTS MY LEGAL RIGHTS AND RESPONSIBILITIES, AND I HEREBY AGREE TO ITS TERMS AND CONDITIONS.

_________________________ ___________________________________

Date Signature of Participant

I (We) hereby consent and agree to the

terms of this release, and hereby waive

any claim (s) as set forth herein.

________________________________

Parent(s)/Guardian (s) Signature (s)

RELEASE FROM LIABILITY

 

 

Release executed on _____________, 2003, by __________________________________. Herein referred to as releasor, to the United States of America, its agencies or departments, its officers, service members, and employees, Venture Crew 935, their heirs, administrators and executors, referred to as a releasee.

I, releasor, being of lawful age, in consideration of being permitted to participate in the 2003 LOUISIANA JUNIOR SHOOTING CAMP at Jackson Barracks, New Orleans, LA, do for myself, my spouse, legal representatives, heirs and assigns, hereby release, waive and forever discharge the United States Government, its agencies or departments, its officers, its service members, employees and Venture Crew 935 in their official and personal capacities, their heirs, and administrators and executors, from all liability, for any and all loss of damage, and from any and every claim, demand, action or right of action, of whatever kind of nature in law of equity, arising from or by reason of death, or any bodily injury or personal injuries known, or property damage resulting or to resulting from any incident which may occur as a result of my participation in 2003 LOUISIANA JUNIOR SHOOTING CAMP or any activities in connection with the 2003 LOUISIANA JUNIOR SHOOTING CAMP whether caused in whole or in part by negligence of releases or otherwise.

I hereby assume full responsibility for the risk or bodily injury, death or property damage due to the negligence of releases or otherwise while at Jackson Barracks, New Orleans, La, and while competing, officiating, working, or as a spectator, or for any purpose participating in the 2003 LOUISIANA JUNIOR SHOOTING CAMP.

I further specifically release the United States Government, and its officers, service members, employees and Venture Crew 935 in their official and personal capacities, from any claim whatsoever on account of first aid, or other medical treatment or service rendered me during my attendance at the 2003 LOUISIANA JUNIOR SHOOTING CAMP.

I agree that this release contracts the entire agreement between myself and the United States of America and the terms of this release are contractual and not mere recital.

I agree that this release agreement is intended to be as broad and inclusive as permitted by law, and that if any portion of it is held invalid, the balance of it will, notwithstanding, continue in full legal force and effect.

I have carefully read this release and understand all its terms. I execute it voluntarily and with full knowledge of its significance.

___________________________________________ _________________________

Signature of Team Member Date

Print Name: ______________________________________________________________________

PARENT/GUARDIAN CONSENT: (Participant under age 18)

___________________________________ ___________________________ ___________

Participant's Name Parent/Guardian Signature Date

______________________________________________________ ___________________________

Signature of Participant Date

Print Name: _________________________________________________________________________________

PARENT/GUARDIAN CONSENT: (Participant under age 18)

______________________________ _________________________________ _______________________

Participant's Name Parent/Guardian Signature Date

 

Contact CSM Mickey Brondum

Telephone 504-682-7597 or 504-343-7597

CLICK HERE TO E-MAIL US.