Loading...

BEYOND THE TEE GOLF CAMPS - HEALTH & RELEASE FORM

If the form is NOT COMPLETED, you/your child will not be able to take part in the program

(Please only complete one time per year. If you have already completed this for 2022, there is no need to do so again unless information has changed.)


I/We verify that the named participant is in good health and completely able to take part in all activities of the Golf Camp or Academy and that I know of no condition, physical impairments, or any unknown facts, which may restrict his/her participation in such a program.

Assumption of the Risk and Waiver of Liability Relating to Coronavirus/COVID-19

The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. Beyond the Tee, LLC has put in place preventative measures to reduce the spread of COVID-19; however, Beyond the Tee, LLC cannot guarantee that you/your child will not become infected with COVID-19. Further, participation could increase one’s risk of contracting COVID-19.

READ CAREFULLY BEFORE SIGNING - INITIAL EACH PARAGRAPH

By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that myself/ my child may be exposed to or infected by COVID-19 by participation; and that such exposure or infection may result in personal injury, illness, permanent disability, and death. I understand that the risk of becoming exposed to or infected by COVID-19 at Beyond the Tee, LLC may result from the actions, omissions, or negligence of myself and others, including, but not limited to, Beyond the Tee, LLC’s employees, volunteers, and program participants and their families.

I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to myself (including, but not limited to, personal injury, disability, and death), illness, damage, loss, claim, liability, or expense, of any kind, that I may experience or incur in connection with my/my child’s participation at Beyond the Tee, LLC. On my behalf, I hereby release, covenant not to sue, discharge, and hold harmless, Beyond the Tee, LLC, its employees, agents, and representatives, of and from the Claims, including all liabilities, claims, actions, damages, costs or expenses of any kind arising out of or relating thereto. I understand and agree that this release includes any Claims based on the actions, omissions, or negligence of Beyond the Tee, LLC, its employees, agents, and representatives, whether a COVID-19 infection occurs before, during, or after participation at Beyond the Tee, LLC. 

I understand that participation in Golf Camp may increase the risk of contracting, and/or spreading COVID-19. I also understand that participation in Golf Camp is voluntary. Therefore, I am voluntarily assuming the risk(s) of COVID-19 and waiving any claims associated therewith. 

I represent that I have adequate insurance to cover any injury or illness I may suffer or cause while participating in this activity, or else I agree to bear the costs of such injury or illness myself. I further represent that I have no medical or physical condition which could interfere with my safety in this activity, or else I am willing to assume - and bear the costs of - all risks that may be created, directly or indirectly, by any such condition. 

In the event that I file a lawsuit, I agree to do so in the State where Beyond the Tee, LLC is located, and I further agree that the substantive law of the state shall apply. I agree that if any portion of this agreement is found to be void or unenforceable, the remaining portions shall remain in full force and effect. 

By signing this document, I agree that if me/ my child is exposed or infected by COVID-19 during their participation in this activity, then I may be found by a court of law to have waived my right to maintain a lawsuit against the parties being released on the basis of any claim for negligence. 

I have had sufficient time to read this entire document and should I choose to do so, consult with legal counsel prior to signing. Also, I understand that this activity might not be made available to me or that the costs to engage in this activity would be significantly greater if I were to choose not to sign this release, and agree that the opportunity to participate at the stated cost in return for the execution of this release is a reasonable bargain. I have read and understood this document and I agree to be bound by its terms. 

If I have signed a separate general waiver of liability connected to my participation at Beyond the Tee, LLC, I agree that the terms of that waiver are wholly incorporated into this document and that the terms of this document are incorporated into the separate general waiver. 

I agree that I/my child will practice safe social distancing and clean hygiene during one’s participation at Beyond the Tee, LLC

 

DATE: September 26, 2022

First Participant's Name

First Name*

Last Name*

Phone*
First Participant's Date of Birth*
First Participant's Information

Gender: *

Age: *

Person to contact in the event I cannot be reached
Please check any of the conditions or illnesses that the participant has experienced:
Measles
Mumps
Asthma
Chicken Pox
Pneumonia
Diabetes
High Blood Pressure

Immunizations

I verify my child has received the following immunizations, and dates could be provided upon request. *
Tetanus
Polio
Measles
Rubella
Mumps

Allergies

Asthma*
No
Yes
Eczema*
No
Yes
Hay Fever*
No
Yes
Insect Stings*
No
Yes
Nuts*
No
Yes

Drug Reaction

Sulpha*
No
Yes
Penicillin*
No
Yes
Antibiotics (type)*
No
Yes

Antibiotics Allergy Type/ Other Allergy:

Physician's Name: *

Phone: *

HEALTH & GENERAL HISTORY


Are there any activities the participant should be prevented from doing?

Are there any medications the participant will be taking during the camp/academy? If yes, please provide the name of the drug and the dosage:

If the participant has any medical history or medical conditions that will require special attention, please specify:

HEALTH INSURANCE INFORMATION


Carrier Name:

Policy Number:

Policy Holder Name:

Policy Holder Date of Birth:

I/We the parent(s) or guardian of minor, give permission for the named participant to receive emergency medical treatment, or surgical treatment and hospitalization if required. I acknowledge that a good faith attempt will be made to contact myself or the emergency contact named above, before taking this action. I will be financially responsible for any and all medical attention required during the camp / academy or resulting from an injury received during camp. My medical insurance will be the only insurance coverage for any medical treatments. I agree that I/my child can receive over the counter medicine. (Tylenol, Benadryl, etc.)

Check here if you DO NOT wish for you/your child to receive over the counter medications.

I HAVE READ THE CAMP/ACADEMY RULES AND REGULATIONS FULLY AND UNDERSTAND OUR AGREEMENT STATED THEREIN AND ALSO THE RIGHTS OF BEYOND THE TEE, LLC AND AGREE TO ACT IN ACCORDANCE. I acknowledge I have received good and adequate consideration, and I hereby grant, release, and quit claim to Beyond the Tee royalty free the right and authority to use, reproduce, and distribute, my/my child's photo, likeness, recorded voice or videotaped camp appearance, or quoted material for advertising and promotional purposes as Beyond The Tee in its sole discretion will deem appropriate.

The undersigned further agrees that the attached waiver and assumption of risks agreement is expected to be as broad and comprehensive as is permitted by law and that if any aspect thereof is held invalid, it is conceded that the balance, notwithstanding, continue in full legal force and effect.

First Participant's Signature*
Second Participant's Name

First Name*

Last Name*
Second Participant's Date of Birth*
Second Participant's Information

Gender: *

Age: *

Person to contact in the event I cannot be reached
Please check any of the conditions or illnesses that the participant has experienced:
Measles
Mumps
Asthma
Chicken Pox
Pneumonia
Diabetes
High Blood Pressure

Immunizations

I verify my child has received the following immunizations, and dates could be provided upon request. *
Tetanus
Polio
Measles
Rubella
Mumps

Allergies

Asthma*
No
Yes
Eczema*
No
Yes
Hay Fever*
No
Yes
Insect Stings*
No
Yes
Nuts*
No
Yes

Drug Reaction

Sulpha*
No
Yes
Penicillin*
No
Yes
Antibiotics (type)*
No
Yes

Antibiotics Allergy Type/ Other Allergy:

Physician's Name: *

Phone: *

HEALTH & GENERAL HISTORY


Are there any activities the participant should be prevented from doing?

Are there any medications the participant will be taking during the camp/academy? If yes, please provide the name of the drug and the dosage:

If the participant has any medical history or medical conditions that will require special attention, please specify:

HEALTH INSURANCE INFORMATION


Carrier Name:

Policy Number:

Policy Holder Name:

Policy Holder Date of Birth:

I/We the parent(s) or guardian of minor, give permission for the named participant to receive emergency medical treatment, or surgical treatment and hospitalization if required. I acknowledge that a good faith attempt will be made to contact myself or the emergency contact named above, before taking this action. I will be financially responsible for any and all medical attention required during the camp / academy or resulting from an injury received during camp. My medical insurance will be the only insurance coverage for any medical treatments. I agree that I/my child can receive over the counter medicine. (Tylenol, Benadryl, etc.)

Check here if you DO NOT wish for you/your child to receive over the counter medications.

I HAVE READ THE CAMP/ACADEMY RULES AND REGULATIONS FULLY AND UNDERSTAND OUR AGREEMENT STATED THEREIN AND ALSO THE RIGHTS OF BEYOND THE TEE, LLC AND AGREE TO ACT IN ACCORDANCE. I acknowledge I have received good and adequate consideration, and I hereby grant, release, and quit claim to Beyond the Tee royalty free the right and authority to use, reproduce, and distribute, my/my child's photo, likeness, recorded voice or videotaped camp appearance, or quoted material for advertising and promotional purposes as Beyond The Tee in its sole discretion will deem appropriate.

The undersigned further agrees that the attached waiver and assumption of risks agreement is expected to be as broad and comprehensive as is permitted by law and that if any aspect thereof is held invalid, it is conceded that the balance, notwithstanding, continue in full legal force and effect.

Third Participant's Name

First Name*

Last Name*
Third Participant's Date of Birth*
Third Participant's Information

Gender: *

Age: *

Person to contact in the event I cannot be reached
Please check any of the conditions or illnesses that the participant has experienced:
Measles
Mumps
Asthma
Chicken Pox
Pneumonia
Diabetes
High Blood Pressure

Immunizations

I verify my child has received the following immunizations, and dates could be provided upon request. *
Tetanus
Polio
Measles
Rubella
Mumps

Allergies

Asthma*
No
Yes
Eczema*
No
Yes
Hay Fever*
No
Yes
Insect Stings*
No
Yes
Nuts*
No
Yes

Drug Reaction

Sulpha*
No
Yes
Penicillin*
No
Yes
Antibiotics (type)*
No
Yes

Antibiotics Allergy Type/ Other Allergy:

Physician's Name: *

Phone: *

HEALTH & GENERAL HISTORY


Are there any activities the participant should be prevented from doing?

Are there any medications the participant will be taking during the camp/academy? If yes, please provide the name of the drug and the dosage:

If the participant has any medical history or medical conditions that will require special attention, please specify:

HEALTH INSURANCE INFORMATION


Carrier Name:

Policy Number:

Policy Holder Name:

Policy Holder Date of Birth:

I/We the parent(s) or guardian of minor, give permission for the named participant to receive emergency medical treatment, or surgical treatment and hospitalization if required. I acknowledge that a good faith attempt will be made to contact myself or the emergency contact named above, before taking this action. I will be financially responsible for any and all medical attention required during the camp / academy or resulting from an injury received during camp. My medical insurance will be the only insurance coverage for any medical treatments. I agree that I/my child can receive over the counter medicine. (Tylenol, Benadryl, etc.)

Check here if you DO NOT wish for you/your child to receive over the counter medications.

I HAVE READ THE CAMP/ACADEMY RULES AND REGULATIONS FULLY AND UNDERSTAND OUR AGREEMENT STATED THEREIN AND ALSO THE RIGHTS OF BEYOND THE TEE, LLC AND AGREE TO ACT IN ACCORDANCE. I acknowledge I have received good and adequate consideration, and I hereby grant, release, and quit claim to Beyond the Tee royalty free the right and authority to use, reproduce, and distribute, my/my child's photo, likeness, recorded voice or videotaped camp appearance, or quoted material for advertising and promotional purposes as Beyond The Tee in its sole discretion will deem appropriate.

The undersigned further agrees that the attached waiver and assumption of risks agreement is expected to be as broad and comprehensive as is permitted by law and that if any aspect thereof is held invalid, it is conceded that the balance, notwithstanding, continue in full legal force and effect.

Fourth Participant's Name

First Name*

Last Name*
Fourth Participant's Date of Birth*
Fourth Participant's Information

Gender: *

Age: *

Person to contact in the event I cannot be reached
Please check any of the conditions or illnesses that the participant has experienced:
Measles
Mumps
Asthma
Chicken Pox
Pneumonia
Diabetes
High Blood Pressure

Immunizations

I verify my child has received the following immunizations, and dates could be provided upon request. *
Tetanus
Polio
Measles
Rubella
Mumps

Allergies

Asthma*
No
Yes
Eczema*
No
Yes
Hay Fever*
No
Yes
Insect Stings*
No
Yes
Nuts*
No
Yes

Drug Reaction

Sulpha*
No
Yes
Penicillin*
No
Yes
Antibiotics (type)*
No
Yes

Antibiotics Allergy Type/ Other Allergy:

Physician's Name: *

Phone: *

HEALTH & GENERAL HISTORY


Are there any activities the participant should be prevented from doing?

Are there any medications the participant will be taking during the camp/academy? If yes, please provide the name of the drug and the dosage:

If the participant has any medical history or medical conditions that will require special attention, please specify:

HEALTH INSURANCE INFORMATION


Carrier Name:

Policy Number:

Policy Holder Name:

Policy Holder Date of Birth:

I/We the parent(s) or guardian of minor, give permission for the named participant to receive emergency medical treatment, or surgical treatment and hospitalization if required. I acknowledge that a good faith attempt will be made to contact myself or the emergency contact named above, before taking this action. I will be financially responsible for any and all medical attention required during the camp / academy or resulting from an injury received during camp. My medical insurance will be the only insurance coverage for any medical treatments. I agree that I/my child can receive over the counter medicine. (Tylenol, Benadryl, etc.)

Check here if you DO NOT wish for you/your child to receive over the counter medications.

I HAVE READ THE CAMP/ACADEMY RULES AND REGULATIONS FULLY AND UNDERSTAND OUR AGREEMENT STATED THEREIN AND ALSO THE RIGHTS OF BEYOND THE TEE, LLC AND AGREE TO ACT IN ACCORDANCE. I acknowledge I have received good and adequate consideration, and I hereby grant, release, and quit claim to Beyond the Tee royalty free the right and authority to use, reproduce, and distribute, my/my child's photo, likeness, recorded voice or videotaped camp appearance, or quoted material for advertising and promotional purposes as Beyond The Tee in its sole discretion will deem appropriate.

The undersigned further agrees that the attached waiver and assumption of risks agreement is expected to be as broad and comprehensive as is permitted by law and that if any aspect thereof is held invalid, it is conceded that the balance, notwithstanding, continue in full legal force and effect.

Fifth Participant's Name

First Name*

Last Name*
Fifth Participant's Date of Birth*
Fifth Participant's Information

Gender: *

Age: *

Person to contact in the event I cannot be reached
Please check any of the conditions or illnesses that the participant has experienced:
Measles
Mumps
Asthma
Chicken Pox
Pneumonia
Diabetes
High Blood Pressure

Immunizations

I verify my child has received the following immunizations, and dates could be provided upon request. *
Tetanus
Polio
Measles
Rubella
Mumps

Allergies

Asthma*
No
Yes
Eczema*
No
Yes
Hay Fever*
No
Yes
Insect Stings*
No
Yes
Nuts*
No
Yes

Drug Reaction

Sulpha*
No
Yes
Penicillin*
No
Yes
Antibiotics (type)*
No
Yes

Antibiotics Allergy Type/ Other Allergy:

Physician's Name: *

Phone: *

HEALTH & GENERAL HISTORY


Are there any activities the participant should be prevented from doing?

Are there any medications the participant will be taking during the camp/academy? If yes, please provide the name of the drug and the dosage:

If the participant has any medical history or medical conditions that will require special attention, please specify:

HEALTH INSURANCE INFORMATION


Carrier Name:

Policy Number:

Policy Holder Name:

Policy Holder Date of Birth:

I/We the parent(s) or guardian of minor, give permission for the named participant to receive emergency medical treatment, or surgical treatment and hospitalization if required. I acknowledge that a good faith attempt will be made to contact myself or the emergency contact named above, before taking this action. I will be financially responsible for any and all medical attention required during the camp / academy or resulting from an injury received during camp. My medical insurance will be the only insurance coverage for any medical treatments. I agree that I/my child can receive over the counter medicine. (Tylenol, Benadryl, etc.)

Check here if you DO NOT wish for you/your child to receive over the counter medications.

I HAVE READ THE CAMP/ACADEMY RULES AND REGULATIONS FULLY AND UNDERSTAND OUR AGREEMENT STATED THEREIN AND ALSO THE RIGHTS OF BEYOND THE TEE, LLC AND AGREE TO ACT IN ACCORDANCE. I acknowledge I have received good and adequate consideration, and I hereby grant, release, and quit claim to Beyond the Tee royalty free the right and authority to use, reproduce, and distribute, my/my child's photo, likeness, recorded voice or videotaped camp appearance, or quoted material for advertising and promotional purposes as Beyond The Tee in its sole discretion will deem appropriate.

The undersigned further agrees that the attached waiver and assumption of risks agreement is expected to be as broad and comprehensive as is permitted by law and that if any aspect thereof is held invalid, it is conceded that the balance, notwithstanding, continue in full legal force and effect.

Sixth Participant's Name

First Name*

Last Name*
Sixth Participant's Date of Birth*
Sixth Participant's Information

Gender: *

Age: *

Person to contact in the event I cannot be reached
Please check any of the conditions or illnesses that the participant has experienced:
Measles
Mumps
Asthma
Chicken Pox
Pneumonia
Diabetes
High Blood Pressure

Immunizations

I verify my child has received the following immunizations, and dates could be provided upon request. *
Tetanus
Polio
Measles
Rubella
Mumps

Allergies

Asthma*
No
Yes
Eczema*
No
Yes
Hay Fever*
No
Yes
Insect Stings*
No
Yes
Nuts*
No
Yes

Drug Reaction

Sulpha*
No
Yes
Penicillin*
No
Yes
Antibiotics (type)*
No
Yes

Antibiotics Allergy Type/ Other Allergy:

Physician's Name: *

Phone: *

HEALTH & GENERAL HISTORY


Are there any activities the participant should be prevented from doing?

Are there any medications the participant will be taking during the camp/academy? If yes, please provide the name of the drug and the dosage:

If the participant has any medical history or medical conditions that will require special attention, please specify:

HEALTH INSURANCE INFORMATION


Carrier Name:

Policy Number:

Policy Holder Name:

Policy Holder Date of Birth:

I/We the parent(s) or guardian of minor, give permission for the named participant to receive emergency medical treatment, or surgical treatment and hospitalization if required. I acknowledge that a good faith attempt will be made to contact myself or the emergency contact named above, before taking this action. I will be financially responsible for any and all medical attention required during the camp / academy or resulting from an injury received during camp. My medical insurance will be the only insurance coverage for any medical treatments. I agree that I/my child can receive over the counter medicine. (Tylenol, Benadryl, etc.)

Check here if you DO NOT wish for you/your child to receive over the counter medications.

I HAVE READ THE CAMP/ACADEMY RULES AND REGULATIONS FULLY AND UNDERSTAND OUR AGREEMENT STATED THEREIN AND ALSO THE RIGHTS OF BEYOND THE TEE, LLC AND AGREE TO ACT IN ACCORDANCE. I acknowledge I have received good and adequate consideration, and I hereby grant, release, and quit claim to Beyond the Tee royalty free the right and authority to use, reproduce, and distribute, my/my child's photo, likeness, recorded voice or videotaped camp appearance, or quoted material for advertising and promotional purposes as Beyond The Tee in its sole discretion will deem appropriate.

The undersigned further agrees that the attached waiver and assumption of risks agreement is expected to be as broad and comprehensive as is permitted by law and that if any aspect thereof is held invalid, it is conceded that the balance, notwithstanding, continue in full legal force and effect.

Seventh Participant's Name

First Name*

Last Name*
Seventh Participant's Date of Birth*
Seventh Participant's Information

Gender: *

Age: *

Person to contact in the event I cannot be reached
Please check any of the conditions or illnesses that the participant has experienced:
Measles
Mumps
Asthma
Chicken Pox
Pneumonia
Diabetes
High Blood Pressure

Immunizations

I verify my child has received the following immunizations, and dates could be provided upon request. *
Tetanus
Polio
Measles
Rubella
Mumps

Allergies

Asthma*
No
Yes
Eczema*
No
Yes
Hay Fever*
No
Yes
Insect Stings*
No
Yes
Nuts*
No
Yes

Drug Reaction

Sulpha*
No
Yes
Penicillin*
No
Yes
Antibiotics (type)*
No
Yes

Antibiotics Allergy Type/ Other Allergy:

Physician's Name: *

Phone: *

HEALTH & GENERAL HISTORY


Are there any activities the participant should be prevented from doing?

Are there any medications the participant will be taking during the camp/academy? If yes, please provide the name of the drug and the dosage:

If the participant has any medical history or medical conditions that will require special attention, please specify:

HEALTH INSURANCE INFORMATION


Carrier Name:

Policy Number:

Policy Holder Name:

Policy Holder Date of Birth:

I/We the parent(s) or guardian of minor, give permission for the named participant to receive emergency medical treatment, or surgical treatment and hospitalization if required. I acknowledge that a good faith attempt will be made to contact myself or the emergency contact named above, before taking this action. I will be financially responsible for any and all medical attention required during the camp / academy or resulting from an injury received during camp. My medical insurance will be the only insurance coverage for any medical treatments. I agree that I/my child can receive over the counter medicine. (Tylenol, Benadryl, etc.)

Check here if you DO NOT wish for you/your child to receive over the counter medications.

I HAVE READ THE CAMP/ACADEMY RULES AND REGULATIONS FULLY AND UNDERSTAND OUR AGREEMENT STATED THEREIN AND ALSO THE RIGHTS OF BEYOND THE TEE, LLC AND AGREE TO ACT IN ACCORDANCE. I acknowledge I have received good and adequate consideration, and I hereby grant, release, and quit claim to Beyond the Tee royalty free the right and authority to use, reproduce, and distribute, my/my child's photo, likeness, recorded voice or videotaped camp appearance, or quoted material for advertising and promotional purposes as Beyond The Tee in its sole discretion will deem appropriate.

The undersigned further agrees that the attached waiver and assumption of risks agreement is expected to be as broad and comprehensive as is permitted by law and that if any aspect thereof is held invalid, it is conceded that the balance, notwithstanding, continue in full legal force and effect.

Eighth Participant's Name

First Name*

Last Name*
Eighth Participant's Date of Birth*
Eighth Participant's Information

Gender: *

Age: *

Person to contact in the event I cannot be reached
Please check any of the conditions or illnesses that the participant has experienced:
Measles
Mumps
Asthma
Chicken Pox
Pneumonia
Diabetes
High Blood Pressure

Immunizations

I verify my child has received the following immunizations, and dates could be provided upon request. *
Tetanus
Polio
Measles
Rubella
Mumps

Allergies

Asthma*
No
Yes
Eczema*
No
Yes
Hay Fever*
No
Yes
Insect Stings*
No
Yes
Nuts*
No
Yes

Drug Reaction

Sulpha*
No
Yes
Penicillin*
No
Yes
Antibiotics (type)*
No
Yes

Antibiotics Allergy Type/ Other Allergy:

Physician's Name: *

Phone: *

HEALTH & GENERAL HISTORY


Are there any activities the participant should be prevented from doing?

Are there any medications the participant will be taking during the camp/academy? If yes, please provide the name of the drug and the dosage:

If the participant has any medical history or medical conditions that will require special attention, please specify:

HEALTH INSURANCE INFORMATION


Carrier Name:

Policy Number:

Policy Holder Name:

Policy Holder Date of Birth:

I/We the parent(s) or guardian of minor, give permission for the named participant to receive emergency medical treatment, or surgical treatment and hospitalization if required. I acknowledge that a good faith attempt will be made to contact myself or the emergency contact named above, before taking this action. I will be financially responsible for any and all medical attention required during the camp / academy or resulting from an injury received during camp. My medical insurance will be the only insurance coverage for any medical treatments. I agree that I/my child can receive over the counter medicine. (Tylenol, Benadryl, etc.)

Check here if you DO NOT wish for you/your child to receive over the counter medications.

I HAVE READ THE CAMP/ACADEMY RULES AND REGULATIONS FULLY AND UNDERSTAND OUR AGREEMENT STATED THEREIN AND ALSO THE RIGHTS OF BEYOND THE TEE, LLC AND AGREE TO ACT IN ACCORDANCE. I acknowledge I have received good and adequate consideration, and I hereby grant, release, and quit claim to Beyond the Tee royalty free the right and authority to use, reproduce, and distribute, my/my child's photo, likeness, recorded voice or videotaped camp appearance, or quoted material for advertising and promotional purposes as Beyond The Tee in its sole discretion will deem appropriate.

The undersigned further agrees that the attached waiver and assumption of risks agreement is expected to be as broad and comprehensive as is permitted by law and that if any aspect thereof is held invalid, it is conceded that the balance, notwithstanding, continue in full legal force and effect.

Ninth Participant's Name

First Name*

Last Name*
Ninth Participant's Date of Birth*
Ninth Participant's Information

Gender: *

Age: *

Person to contact in the event I cannot be reached
Please check any of the conditions or illnesses that the participant has experienced:
Measles
Mumps
Asthma
Chicken Pox
Pneumonia
Diabetes
High Blood Pressure

Immunizations

I verify my child has received the following immunizations, and dates could be provided upon request. *
Tetanus
Polio
Measles
Rubella
Mumps

Allergies

Asthma*
No
Yes
Eczema*
No
Yes
Hay Fever*
No
Yes
Insect Stings*
No
Yes
Nuts*
No
Yes

Drug Reaction

Sulpha*
No
Yes
Penicillin*
No
Yes
Antibiotics (type)*
No
Yes

Antibiotics Allergy Type/ Other Allergy:

Physician's Name: *

Phone: *

HEALTH & GENERAL HISTORY


Are there any activities the participant should be prevented from doing?

Are there any medications the participant will be taking during the camp/academy? If yes, please provide the name of the drug and the dosage:

If the participant has any medical history or medical conditions that will require special attention, please specify:

HEALTH INSURANCE INFORMATION


Carrier Name:

Policy Number:

Policy Holder Name:

Policy Holder Date of Birth:

I/We the parent(s) or guardian of minor, give permission for the named participant to receive emergency medical treatment, or surgical treatment and hospitalization if required. I acknowledge that a good faith attempt will be made to contact myself or the emergency contact named above, before taking this action. I will be financially responsible for any and all medical attention required during the camp / academy or resulting from an injury received during camp. My medical insurance will be the only insurance coverage for any medical treatments. I agree that I/my child can receive over the counter medicine. (Tylenol, Benadryl, etc.)

Check here if you DO NOT wish for you/your child to receive over the counter medications.

I HAVE READ THE CAMP/ACADEMY RULES AND REGULATIONS FULLY AND UNDERSTAND OUR AGREEMENT STATED THEREIN AND ALSO THE RIGHTS OF BEYOND THE TEE, LLC AND AGREE TO ACT IN ACCORDANCE. I acknowledge I have received good and adequate consideration, and I hereby grant, release, and quit claim to Beyond the Tee royalty free the right and authority to use, reproduce, and distribute, my/my child's photo, likeness, recorded voice or videotaped camp appearance, or quoted material for advertising and promotional purposes as Beyond The Tee in its sole discretion will deem appropriate.

The undersigned further agrees that the attached waiver and assumption of risks agreement is expected to be as broad and comprehensive as is permitted by law and that if any aspect thereof is held invalid, it is conceded that the balance, notwithstanding, continue in full legal force and effect.

Tenth Participant's Name

First Name*

Last Name*
Tenth Participant's Date of Birth*
Tenth Participant's Information

Gender: *

Age: *

Person to contact in the event I cannot be reached
Please check any of the conditions or illnesses that the participant has experienced:
Measles
Mumps
Asthma
Chicken Pox
Pneumonia
Diabetes
High Blood Pressure

Immunizations

I verify my child has received the following immunizations, and dates could be provided upon request. *
Tetanus
Polio
Measles
Rubella
Mumps

Allergies

Asthma*
No
Yes
Eczema*
No
Yes
Hay Fever*
No
Yes
Insect Stings*
No
Yes
Nuts*
No
Yes

Drug Reaction

Sulpha*
No
Yes
Penicillin*
No
Yes
Antibiotics (type)*
No
Yes

Antibiotics Allergy Type/ Other Allergy:

Physician's Name: *

Phone: *

HEALTH & GENERAL HISTORY


Are there any activities the participant should be prevented from doing?

Are there any medications the participant will be taking during the camp/academy? If yes, please provide the name of the drug and the dosage:

If the participant has any medical history or medical conditions that will require special attention, please specify:

HEALTH INSURANCE INFORMATION


Carrier Name:

Policy Number:

Policy Holder Name:

Policy Holder Date of Birth:

I/We the parent(s) or guardian of minor, give permission for the named participant to receive emergency medical treatment, or surgical treatment and hospitalization if required. I acknowledge that a good faith attempt will be made to contact myself or the emergency contact named above, before taking this action. I will be financially responsible for any and all medical attention required during the camp / academy or resulting from an injury received during camp. My medical insurance will be the only insurance coverage for any medical treatments. I agree that I/my child can receive over the counter medicine. (Tylenol, Benadryl, etc.)

Check here if you DO NOT wish for you/your child to receive over the counter medications.

I HAVE READ THE CAMP/ACADEMY RULES AND REGULATIONS FULLY AND UNDERSTAND OUR AGREEMENT STATED THEREIN AND ALSO THE RIGHTS OF BEYOND THE TEE, LLC AND AGREE TO ACT IN ACCORDANCE. I acknowledge I have received good and adequate consideration, and I hereby grant, release, and quit claim to Beyond the Tee royalty free the right and authority to use, reproduce, and distribute, my/my child's photo, likeness, recorded voice or videotaped camp appearance, or quoted material for advertising and promotional purposes as Beyond The Tee in its sole discretion will deem appropriate.

The undersigned further agrees that the attached waiver and assumption of risks agreement is expected to be as broad and comprehensive as is permitted by law and that if any aspect thereof is held invalid, it is conceded that the balance, notwithstanding, continue in full legal force and effect.

Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
PARENT OR GUARDIAN ADDITIONAL AGREEMENT (Must be completed for participants under the age of 18): In consideration of minor(s) being permitted to participate in this activity. I further agree to indemnify and hold harmless Releasees from any claims alleging negligence which are brought by or on behalf of minor or are in any way connected with such participation by minor.

By signing below the parent or court-appointed legal guardian agrees that they are also subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Gender: *

Age: *

Person to contact in the event I cannot be reached
Please check any of the conditions or illnesses that the participant has experienced:
Measles
Mumps
Asthma
Chicken Pox
Pneumonia
Diabetes
High Blood Pressure

Immunizations

I verify my child has received the following immunizations, and dates could be provided upon request. *
Tetanus
Polio
Measles
Rubella
Mumps

Allergies

Asthma*
No
Yes
Eczema*
No
Yes
Hay Fever*
No
Yes
Insect Stings*
No
Yes
Nuts*
No
Yes

Drug Reaction

Sulpha*
No
Yes
Penicillin*
No
Yes
Antibiotics (type)*
No
Yes

Antibiotics Allergy Type/ Other Allergy:

Physician's Name: *

Phone: *

HEALTH & GENERAL HISTORY


Are there any activities the participant should be prevented from doing?

Are there any medications the participant will be taking during the camp/academy? If yes, please provide the name of the drug and the dosage:

If the participant has any medical history or medical conditions that will require special attention, please specify:

HEALTH INSURANCE INFORMATION


Carrier Name:

Policy Number:

Policy Holder Name:

Policy Holder Date of Birth:

I/We the parent(s) or guardian of minor, give permission for the named participant to receive emergency medical treatment, or surgical treatment and hospitalization if required. I acknowledge that a good faith attempt will be made to contact myself or the emergency contact named above, before taking this action. I will be financially responsible for any and all medical attention required during the camp / academy or resulting from an injury received during camp. My medical insurance will be the only insurance coverage for any medical treatments. I agree that I/my child can receive over the counter medicine. (Tylenol, Benadryl, etc.)

Check here if you DO NOT wish for you/your child to receive over the counter medications.

I HAVE READ THE CAMP/ACADEMY RULES AND REGULATIONS FULLY AND UNDERSTAND OUR AGREEMENT STATED THEREIN AND ALSO THE RIGHTS OF BEYOND THE TEE, LLC AND AGREE TO ACT IN ACCORDANCE. I acknowledge I have received good and adequate consideration, and I hereby grant, release, and quit claim to Beyond the Tee royalty free the right and authority to use, reproduce, and distribute, my/my child's photo, likeness, recorded voice or videotaped camp appearance, or quoted material for advertising and promotional purposes as Beyond The Tee in its sole discretion will deem appropriate.

The undersigned further agrees that the attached waiver and assumption of risks agreement is expected to be as broad and comprehensive as is permitted by law and that if any aspect thereof is held invalid, it is conceded that the balance, notwithstanding, continue in full legal force and effect.

Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


One or more problems exist. Please scroll up.




Powered by  Smartwaiver - TRY IT FREE!