Please print clearly. Mail in or fax to 757-441-2530

Norfolk Youth Sports Week
c/o Norfolk Sheriff Foundation
P.O. Box 3236
Norfolk, VA 23514

Name ________________________________
Phone (        ) _________________________

Name ________________________________
Phone (        ) _________________________

NORFOLK YOUTH SPORTS CAMP
PERMISSION AND WAIVER

I am the parent or legal guardian for the child on this registration form, who is 10 to 14 years of age.  I grant permission for the volunteer staff of the Youth Sports Camps to act on my behalf for my child in granting permission for evaluation and treatment or minor medical problems. I understand that should a major medical problem arise, reasonable attempts will be made to reach me by telephone at the number(s) I have listed. If I cannot be reached, I hereby give my consent to such medical treatment as deemed necessary by a certified Athletic Trainer, Emergency Medical Technician (EMT) and/or a licensed physician. I understand that the Norfolk Sheriff Foundation, a 501(c)(3)charitable foundation, does not provide any accident and medical insurance and that I will be financially responsible for any and all medical expenses related to injuries sustained during the camp. I have actual knowledge of the inherent dangers, risks and injuries involved in football and basketball, contact sports. In addition, I, for myself, my child, my heirs, and personal representatives, hereby waive, release, and discharge forever any and all claims of damages for bodily injury, death, or damage or loss of property in any way related to my child’s participation in this camp, that I or my child may have or that may accrue subsequently to me or to my child against any and all departments or divisions of the Norfolk Sheriff Foundation, the City of Norfolk, the Commonwealth of Virginia, Old Dominion University, Norfolk Public Schools and all employees and agents of such entities.

Further, I hereby give to the Norfolk Sheriff Foundation and its agents, permission to use my child’s image/photograph/name/voice for promotional and educational purposes on behalf of the camp (including but not limited to brochures, booklets, videotapes, reports, press releases, websites and exhibits).

Proof of age is required (Birth certificate, military ID, passport, certified school records or insurance policy).

• I have read, or have had read to me, this general permission and waiver of claims statement.  I understand and voluntarily agree to its provisions.




Parent/Guardian Signature_______________________________

Parent/Guardian print name______________________________