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Camp Release Form

                     

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.

 

 

Daughter’s Name:

 

 

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

 

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