Missoula Fencing Association

3333 Eldora Ln.

Missoula, MT  59803

(406) 251-4623  missoulafencing@hotmail.com

 

FENCING CLASS REGISTRATION

 

NAME_____________________________   AGE__________ DOB____________________

 

ADDRESS____________________________  CITY_________________  ZIP____________

 

GENDER:  M   F   PARENT/GUARDIAN OF MINOR________________________________

 

HOME PHONE______________________  OTHER PHONE __________________________

 

EMAIL:_____________________________________________________________________

 

EMERGENCY CONTACT:_____________________________________________________

 

PRIOR FENCING EXPERIENCE________________________________________________

 

Program registering for:

                    U8 Intro (6-8 yrs old) --$60    Start Date__________         

                    Intro (9 to adult) --$90  Start Date________

                    Home School Club--(fall semester 2012-13: 1st-3rd grd  $75, 4th-12th grd  $150)

                    U8 Club--$60

                    Youth Club-- with own equipment-- $75, using club equipment-- $85
                             Varsity Team (Coach invite only) Club tuition plus $30  

                    Adult Club--$50

 

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, any instructors, and the facility owner 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, any instructors, or the facility owners liable for any injury that may result from participation in this class.

Signature of Parent/Guardian/Participant:________________________________________ 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