Michele Smith Holiday Camp 2016 – Release Form
I hereby certify that my daughter ______________________ has permission to participate in the Michele Smith Developmental Clinic in Clearwater, Florida. I absolve Michele Smith, Michele Smith, Inc., the City of St Pete/Clearwater and any and all parties affiliated with Michele Smith, Michele Smith, Inc., the City of St Pete/Clearwater or the Eddie C. Moore Sports Complex of any and all liability for injury, sickness or fatality suffered by my daughter during this Camp. I agree that completing and returning this release form via email constitutes my official and legal signature.
Parent Name (print):
Parents Phone Number:
Emergeny Contact: Emergency Phone Number:
Parent Signature:___________________________________________________ Date Signed:
Return: Please complete and sign this form. Please complete this form and mail back to us at:
6800 Gulfport Blvd South STE201 #700, St. Petersburg, FL 33706