I hereby authorize Steve Hamann and the staff of the “Steve Hamann Water Polo Clinic for Goalkeepers and Coaches” to act for me according to their best judgment in any emergency requiring medical attention for

____________________________________. And I hereby waive and release Wylie E. Groves High School District, the athletic department, clinic director, and clinic staff members from any and all liability for any injuries or illnesses incurred while at the clinic. I understand that I will be financially responsible for all charges and fees incurred in the rendering of said emergency treatment, regardless of whether or not my medical insurance would cover such costs. I further understand that I am required to maintain and carry accident insurance coverage for the person listed on this application and verify that the coverage information is accurate and true. I have no knowledge of any physical or mental impairment that would affect the above named applicant's participation in the goalkeeper clinic.

Applicant Name ___________________________________    Applicant signature ___________________________

Parent/Guardian signature_____________________________

Parent/Guardian Work Phone# ______________________      Parent/Guardian Home Phone___________________

Medical Insurance Name __________________________       Medical Insurance Policy # ____________________

If parent/guardian cannot be contacted:

Name of Friend/Relative __________________________         Phone # of Friend/Relative _____________________

Allergies_______________________________                   Is camper presently on medication? Y or N

Medical concerns to be aware of: ____________                If so, what?______________________________