JERRY PRESCHUTTI'S PINE FOREST CHEERLEADING CAMP
MEDICAL, TREATMENT AUTHORIZATION
AND LIABILITY RELEASE

_________________________________		_________________________________
School		Camper's Name
_________________________________		_________________________________
Camp Dates		Name of Parent or Guardian
_________________________________		_________________________________
Camper's Birth Date		Parent or Guardian's Home Address
_________________________________		_________________________________
Camper's Social Security #		City         State         Zip

I. the undersigned parent or guardian, do hereby grant permission for my daughter/son, _________________ ,to attend the above Jerry Preschutti's Cheerleading Camp (the "Camp"). In order that my daughter/son may receive the
necessary medical treatment in the event she/he may sustain injury or illness during the period of the Camp. I hereby authorize the Camp Director to obtain medical treatment for my daughter/son for such injury or illness during the Camp, and I hereby hold J.P. Sports Traditions, Inc. (d.b.a. Jerry Preschutti's Cheerleading Camp), Varsity Spirit Corporation and Universal Cheerleaders Association, and their respective officers, employees, directors, shareholders, administrators, agents, contractors, sponsoring agencies, sponsors, advertisers, and if applicable, owners and lessors of premises used to conduct the Camp (all of which are hereinafter referred to as "Releasees") harmless in the exercise of any such authority.

I further acknowledge and understand that in participating in the Camp, there is a possibility that my daughter/son may sustain physical illness or injury (minimal, serious or catastrophic), in connection with her/his participation, and I further release Releasees from any claims for personal illness or injury that my daughter/son may sustain during camp. I further acknowledge and understand that my daughter/son is assuming the risk of such physical illness or injury by his/her participation, and I further release Releasees from any claims for personal illness or injury that my daughter/son may sustain during the Camp.

I further acknowledge and understand that I will be responsible for any medical bills that may be incurred on behalf of my daughter/son for physical illness or injury that she/he may sustain during the Camp.

I authorize the Camp administrative staff if necessary, to give my daughter/son non-prescription medicine (Tylenol, Benadryl, cold/allergy remedy, etc.) while attending the Camp.

_________________________________		_________________________________
Signature of Parent or Guardian		Participant's Signature
_________________________________		_________________________________
Work Phone Number Mother/Father		If Parent Can't Be Reached Contact
		_________________________________
Date ___________________		Contact Emergency Phone Number

Insurance Information (Please complete all information where applicable)

Insurance Company/Plan Administrator:_____________________________________
Group Number: __________ Agreement #:_______ Network Code:_______________
Name of Plan:______________________ Type of Coverage: ____________________
Name of Parent/Guardian Appearing or Medical Card:__________________________

Please provide any information concerning your daughter/sons's health (Allergies, Medications, Injuries, etc.). as well as any information not listed above that appears on your medical card and/or any special billing requirements that your employer and/of insurance company requires: ________________________________________ ______________________________________________________________________

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