USJ Summer Camp/Class Registration

Name of camp/class for which you are registering:
Student's Name
Mailing Address:
City:
State:
Zip:
E-mail:
Phone:
School:
Rising Grade:
Date of Birth:
Parent/Guardian Names:
Father's Work Phone:
Mother's Work Phone:
Family's Physician:
Family's Physician Phone:
Emergency Contact:
Emergency Contact Phone:
Health Problems:
Release/Permission Clause:	I/WE THE UNDERSIGNED PARENT(S) OR GUARDIAN(S) OF THE ABOVE STUDENT IN THE SUMMER PROGRAM OF THE UNIVERSITY SCHOOL OF JACKSON DO HEREBY RELEASE AND DISCHARGE THE SCHOOL (USJ) AND ITS AUTHORIZED REPRESENTATIVES AND STAFF FROM ALL LIABILITY OF ANY KIND AND CHARACTER UPON CLAIM, DEMAND OR CAUSE OF ACTION WHICH MIGHT BE ASSERTED IN BEHALF OF SAID MINOR AGAINST SCHOOL, REPRESENTATIVE OR STAFF, FURTHERMORE, IN THE EVENT OF ACCIDENT, IF THE SAID STAFF OR REPRESENTATIVE TO ADMINISTER NECESSARY FIRST AID, AND/OR TAKE A STUDENT TO THE NEAREST MEDICAL FACILITY FOR ADDITIONAL TREATMENT.
	I agree.