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