Grade: (Circle One…Fall 2009) 4th 5th 6th 7th 8th

Address:____________________________

City: ____________________________

State: _____ Zip:_________ Phone Number _________________

Email: _________________________________

Offense Football Position: (Circle One)  TE   OL  RB   WR  QB

Defense Football Position: (Circle One) LB DL DB

Football T-Shirt size: S M L

School: _____________________________

Enclosed is:__($325.00) Payment in Full __ $100.00 Deposit (Balance due by May 21st.)
(Check one)

My child has permission to attend Arizona Youth Football Camp. Enclosed is the payment in full or
the 100.00 deposit for the June 2nd-June 11th Camp dates. I understand the 100.00 deposit will apply
toward the camp tuition, the balance which will be paid by May 18th. 2009. I have no knowledge of
any physical impairment that would affect or be affected by my child’s participation in the Arizona
Youth Football Camp. In the event of any emergency in which my child requires medical care,
I authorize the staff of the Arizona Youth Football Camp to act for me to obtain whatever medical
treatment the staff in its best judgment deems necessary and appropriate. I specifically consent to such
treatment including but not limited to hospitalization and surgery and will be responsible for any medical
or other charges in connection with attendance at the camp. I acknowledge that at the Arizona Youth Football Camp my child will participate in a sport that may involve, among other things, physical contact
of the body with other persons or objects, including the ground, that at the Arizona Youth Football Camp he may incur a risk of injury. I specifically waive and give up and release the Arizona Youth Football Camp, its owners and staff from liability for any claim for damages which I or my child may have for injuries or illness that he sustain at the Arizona Youth Football Camp. I authorize the Arizona Youth Football
Camp to use any photographs or articles about my child for publicity purposes.

My child is covered by Insurance Company _______________________________

Policy Number: _______________________________

Signature of Parent or Legal Guardian Signature - ______________________________

Print Name __________________________________

Make check payable to: Arizona Youth Football Camp

mail to:
Coach Javier Zuluaga
1938 E. Carver Road
Tempe, AZ 85284

Sponsored By: