PARTICIPANTS:

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(LAST)                                     (FIRST)                                   (MIDDLE)

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(LAST)                                     (FIRST)                                   (MIDDLE)

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(LAST)                                     (FIRST)                                   (MIDDLE)

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(LAST)                                     (FIRST)                                   (MIDDLE)

PARENTAL AUTHORIZATION
    I, parent or guardian of the above named Sports Academy Participants, hereby gives approval to his/her participation in any and all activities during the current Academy.  I assume all risks and hazards incidental to such participation including transportation  to and  from the  activities; and  do hereby  waive,  release, absolve, indemnify and agree to hold harmless the organizers, Missouri Western State University professional staff, instructors, counselors, participants, and persons transporting the participants to and from activities, for any claim arising out of an injury to the participants.
    I also grant permission to managing personnel or other academy representative to authorize and obtain medical care from any licensed physician, hospital, or medical clinic should the participants become ill or injured while participating in academy activities, or at other times when neither parent is available to grant authorization for emergency treatment.
    I authorize the organizers, Missouri Western State University professional staff, to use pictures taken of the above named Sports Academy Participants, in future Sports Academy literature and presentations at State and National Conferences.

Please list any allergies or medical problems, and if the child is on medication. What type of medication is the child allergic to, if any?_________________________________________

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Signature of Parent/Guardian                                    Relationship                     Date

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Address                                              City                          State                  Zip

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Home phone                             Cell phone                                         Office phone