2008 Chuck Broyles Option/Passing Camp
Registration Form



Name____________________________________________________________

Address_________________________________________________________

City_______________________________________State________________

Zip_____________________________________________________________

School__________________________________________________________

Coach___________________________________________________________

Parent’s Home Phone (___)_______________________________________

Parent’s Work Phone (___)_______________________________________

Grade Entering____________Age___________Ht__________Wt__________

Position (circle)   QB   RB   WR   TE

T-Shirt size (circle one)  L  XL  XXL

NO REFUNDS


I hereby grant permission for my child,

________________________________________________________________

to participate in the Chuck Broyles Option/Passing Camp. My child has not suffered any illnesses in the past that would make participation in the camp a risk. I further agree to release from any liability, the Chuck Broyles Option Passing Camp, its staff, Pittsburg State University and the Kansas Board of Regents for any injury or illness suffered by my child while attending or traveling to or from this camp. I further authorize the staff of the Chuck Broyles Option/Passing Camp to act for me in case of any medical emergency because of injury or illness to my child. I acknowlege that I am aware that participation in this camp will require physical activities of a nature which could result in injury to participants notwithstanding the absence of fault on the part of the camp, its staff, Pittsburg State University and the Kansas Board of Regents. The camp staff has explained to me the particular activites to my satisfaction and I am hearby authorizing my child to participate in these activities.

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Signature of Parent / Guardian                                                       Date

________________________________________________________________
Insurance Company                                                                       Insurance Policy


Make checks payable to "Chuck Broyles Option/Passing Camp"

Mail check and registration form to:
Chuck Broyles Option/Passing Camp
1701 S. Broadway
Pittsburg, KS 66762
Office Phone: (620) 235-4663

**NOTE**  If you would like confirmation that your registration & fees have been received, please email us at: football@pittstate.edu.