Missoula Fencing Association

3333 Eldora LN.
Missoula, MT  59803
(406) 251-4623
missoulafencing@hotmail.com

Registration form for Summer Programs 2012

Classes will be held at Missoula Fencing Association, 1200 Shakespeare Ste A, in Missoula.  Please designate which camp you will be attending and mail your registration form to the above address.   Payment must accompany registration and checks can be made payable to MFA.

                                    FENCING CAMP REGISTRATION

NAME_____________________________ AGE__________ DOB____________________
ADDRESS____________________________ CITY_________________ ZIP____________
GENDER: M F PARENT/GUARDIAN___________________________________________
HOME PHONE______________________ OTHER PHONE __________________________
EMAIL:___________________________ EMERGENCY CONTACT:___________________
PRIOR FENCING EXPERIENCE________________________________________________
____________________________________________________________________________

Introductory Camps:

Intro Camp-- June 18th-22nd,   Ages 10-16   ($100): ______ 
U9 Intro Camp-- July 9th-13th,  Ages 6-9 ($80): ________

Weapon Specific Camps (prior fencing experience required):

Saber Camp – July 16th-20th ($100)______

Epee Camp –Ages 10-17, July 23rd-27th ($100)______

Foil Camp –Ages 10-17, August 6th-10th ($100)______

 

Waiver:
I understand that serious, catastrophic, and perhaps fatal injury may result from participation in any sport or athletic activity. I have enrolled ______________________in this program. I know, understand and appreciate the nature of this program and its activities, the benefits to expect and the inherent risks involved in participation. I fully know and understand that participation is voluntary and I am free to discontinue participation at any time. I also understand that MYFA, Inc., Laura Lee, and any instructors do not provide insurance coverage for participants. My signature here indicates I have read and understand the above and agree not to hold MYFA, Inc., Laura Lee, and any instructors liable for any injury that may result from participation in this class.

Signature of Participant/Guardian:________________________________________ Date:____________

 

 HEALTH HISTORY/MEDICAL RELEASE
 

            NAME:_______________________________________________
            ADDRESS:____________________________________________  _____________________________________________________                                                     AGE:________ DOB:__________ PHONE:__________________
            EMERGENCY CONTACT:_______________________________
            Insurance Co. and Policy #:___________________________________
            _________________________________________________________

PERSONAL MEDICAL HISTORY (current or in past)
                                                                        Explain
            HEART DISEASE       YES     NO      _______________________
            HEART MURMUR      YES     NO      _______________________
            HEART SURGERY     YES     NO      _______________________
            DIABETES                  YES     NO      _______________________
            MUSCLE DISEASE    YES     NO      _______________________
            LUNG DISEASE         YES     NO      _______________________
            EPILEPSY                   YES     NO      _______________________
 

           Chest pains                   YES     NO      _______________________
            Dizzy spells                  YES     NO      _______________________
            Black outs                    YES     NO      _______________________
            Irregular heart beat       YES     NO      _______________________ 

Have you recently had any broken, sprained, or bruised bones or muscles? 
             YES     NO            _____________________________

Current medications and condition(s) you are treating:
________________________________________________________________
________________________________________________________________
List any known allergies to medications:__________________________________
List any specific needs or explain any medical problems that may not have been covered
__________________________________________________________________
_________________________________________________________________

I hereby give my consent for emergency medical care prescribed by a duly licensed medical provider.  This care may be given under whatever conditions are necessary to preserve life, limb or well-being.

_______________________________                            ________________
Parent/Guardian/Participant Signature                                  Date