Fifth Annual
Blue Chip Invitational Football Academy
Dean College - Franklin, Massachusetts
June 29 - July 1, 2010
Registration Form
Name_______________________________________________ School_____________________________________
Address_____________________________________________
City________________________________ State________ Zip____________
Phone______________________________ Email__________________________________
DOB_______________________________ Grade in 2010-2011____________________________
HT_____________ WT_____________ GPA______________ SAT______________Circle one Offensive and one Defensive Position:
Offense: QB RB WR TE OL Defense: DB LB DL
Total Fee: $395.00 due on or before June 10, 2010 - All payments are non-refundable - ( Make checks payable to: Blue Chip Football Academy.)
Parent/Guardian Release From
Please read this form carefully and be aware that signing up for and participating in programs/activities, you will be expressly assuming the risk and legal liability and waiving and releasing all claims for injuries, damages or loss which you might sustain as a result of participating in any and all activities connected with and associated with said programs/activities (including transportation services/vehicle operation, when provided). I recognize and acknowledge that there are certain risks of physical injury to participants in these programs/activities, and I voluntarily agree to assume the full risk of any and all injuries, damages or loss, regardless of severity, that my minor child/ward or I may sustain as a result of said participation. If a catastrophic injury should occur, by signing this waiver you the parent/guardian and/or athlete give permission to any event staff and/or medical professional to treat and assess any injuries that may have occurred during the activities. Also, signing this waiver permits medical professionals to take the athlete off site if further care is necessary. I further agree to waive and relinquish all claims against the Blue Chip Football Academy or Dean College, including their officials, agents, volunteers and employees (hereinafter collectively referred to as BCFA), which I may have (or that accrue to me) as a result of participating in these programs/activities. I do hereby fully release and forever discharge the BCFA from any and all claims for injuries, damages, or loss that I may have or which may accrue to me arising out of, connected with, or in any way associated with these programs/activities. I give permission to BCFA and or Dean College to photograph, videotape or post images of my son on the BCFA website or promotional materials.It is understood that our advertised staff for the 2010 BCFA is scheduled to attend (2006-2009 advertised staff had 100% attendance) but due to unforeseen personal circumstances or changes in NCAA rules after 1/15/2010 the BCFA cannot guarantee attendance by any individual or group of staff members. I have read and fully understand the above important information, warning or risk, and waiver and release of all claims. It is understood that all medical, dental or emergency treatment expenses are the responsibility of the athlete or his parents. If registering via fax, I understand my signature shall substitute for and have the same legal effect as an original form signature.
Emergency Contact Name_____________________________ Phone_______________________________
Medical Conditions/allergies a physician should be aware of_______________________________________
Insurance Company____________________________________________ Phone______________________
Policy # ___________________________________________________________
I have read and agree to the terms stated in the Parent/Guardian Release Form:
Student Athlete Name (please print) ________________________________ Date ____________
Parent/Guardian (please print) ____________________________________ Date _____________
Parent/Guardian Signature _________________________________________________________
Please complete this form completely and return with your payment prior to April 10,2010 to:
Blue Chip Football Academy
PO Box 187
Mendon, MA 01756