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REACH Basketball Hoops Camp Session II, 9:00-11:30(1st-8th Grade)2020 on Monday, July 13, 2020 @ 9:00 AM

*Attendee's Date of Birth:
Any known Allergies:
*Parent First Name:
*Parent Last Name:
*Parent Date of Birth:
*Parent Cell #:
*Emergency Contact Name (if parent cannot be reached):
*Emergency Contact Phone #:
I hereby authorize the REACH Instructor to release my child ONLY to the person listed below.
Name of person child may be released to:
Cell # of person child may be released to:
*School Attending:
Teammate Requests (up to 3):
Are you a member of MDPC:
Would you like more information about MDPC:
Any refund due to cancellation will result in a minimum of a $20 cancellation fee.
Indemnity and General Release
  • In the event that I (or my child) am injured, or should require medical or dental attention while participating in a REACH class, I hereby authorize the church representatives or instructors to secure necessary medical treatment. I also acknowledge that ultimately I will be responsible for the cost of any medical care should the cost of that medical care not be reimbursed by the health insurance provider.
  • I do hereby release, forever discharge, and agree to hold harmless MDPC and the directors thereof from any and all liability, claim of demands for personal injury, sickness or death, as well as property damage and expenses, of any nature whatsoever, which may be incurred by the above-named person.
  • I understand that the REACH program is not licensed by the state.
  • I give my permission for any videos or photographs taken of the student to be used on the MDPC website or any MDPC publication.
  • All children must be walked into their classroom by their parent/guardian. The parent/guardian must return to the classroom to pick up the child. The REACH program, MDPC and instructors will not assume responsibility for a child who has not been brought into their classroom by an adult when they arrive.

"I verify that I have read the indemnity and General Release above."  (Please so indicate by checking the box below.)

*Full Name of Parent/Guardian Agreeing to Terms/Conditions: