2010 PURE ATHLETICISM REGISTRATION FORM

Referred by:                                                                                                                                              

Week 1              Week 2              Week 3              Week 4              Week 5              Week 6              Week 7              Week 8              

Participant’s Name:                                                                                                 Age:                      Amount Enclosed:                              

Address:                                                                                                                                                  Zip Code:                                         

Parent/Guardian(s):                                                                                                                          Home Phone:                                         

E-mail Address:                                                                                                                            Alternate Phone:                                         

Emergency Contact:                                                                                                                 Emergency Phone:                                         

I hereby authorize the staff of PureAthleticism Baseball Camp to act for me according to their best judgment in any emergency requiring medical attention and I hereby waive and release the camp from any and all liability for injuries or illnesses incurred while at camp.

Parent/Guardian Signature                                                                                                                              Date                                         

Please make checks payable to:         PureAthleticism

3911 W. Bertona St.

Seattle, WA 98199