2. Name*
3. Email Address
5. Address*
7. City*
8. State*
9. Zip Code*
11. Phone Number*
12. School*
14. Date of Birth*
15. Emergency Contact Number*

    If I cannot be reached, I hereby consent to transportation by ambulance of my child to the nearest medical facility for medical treatment at my expense if deemed necessary by the coach or supervisor of this activity.

17. MAIL FORM & PAYMENT TO: SCRD, 247 Fore Dr. Suite 201 GATE CITY, VA 24251.

19. COVID CHANGES – ATTENDEES SHOULD BRING THEIR OWN WATER/BEVERAGE AS WE WILL NOT PROVIDE WATER AS IN THE PAST

21. CLINIC DATES ARE LISTED BELOW:

    June 12, 19, 26; July 3, 10

22. Cost(s) are $40 per person for the entire summer; $60 per family

    Boys & Girls Ages 8-10                     9-10:30 a.m.

    Boys & Girls Ages 11-14                   10:30-noon

24. If numbers dictate, clinic may be combined for one clinic time

26. COVENANT NOT TO SUE, RELEASE AND INDEMNITY AGREEMENT

                In consideration of the acceptance of my application for this activity, I hereby covenant not to sue the organizers, the promoters, sponsors, the officials, the County of Scott, the Scott County School System or any of their employees, agents or representatives involved with this activity and I forever waive, release and discharge said individuals and entities and each of them from any and all claims for personal injury or property damage which I may have or which may subsequently occur to me as a result of my participation in this activity and I hereby agree to indemnify and save and hold harmless said individuals and entities and each of them from any loss, liability damage or cost they or each of them might incur due to my presence or participation in this activity.

                It is expressly agreed that the forgoing not to sue, release, discharge, waiver and indemnity agreement is intended to be as broad and inclusive as is permitted by the laws of the Commonwealth of Virginia and furthermore binding on my heirs, executors and assigns.

                I recognize that there may be difficulties involved with this activity and I certify that I am sufficiently physically fit to participate in such an activity and I have no physical limitations or restrictions which would prohibit my participation nor have I been advised by a physician that I have such limitations or restrictions.

    If you have any questions, please call the SCRD at 276-452-2442.

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