Triple Threat Academy
Spring 2010
April 5-7  -   9-2pm
Bishop O'Dowd HS

Price = $130 per child

Student's Full Name: ________________________________________

T-Shirt (Adult Sizes)  XS     S      M      L      XL      XXL

Grade: ______ School: _______________________________ Sex: ______

Parent or Guardian: _______________________________________

Home Phone: _____________________ Cel/Work Phone: __________________

Address: _______________________________________________________

City:__________________________________ Zip: ______________________

Email ___________________________________________________________ (used for confirmation)

Waiver of Liability: I, the undersigned, do hereby waive, release, and discharge
all claims for damages, death, personal injury which may occur or which may
hereafter accrue as a result of participation in Triple Threat Academy Camps. Knowing
the risks of the activity, I hereby agree to assume those risks. This release is intended
to discharge and hold harmless Triple Threat Academy, LLC and its employees from liability.
This waiver and assumption of risk is to be binding on my heirs and assigns. I further
understand that photographs may be taken of my child during the course of the clinic
and these may be used in Triple Threat Academy, LLC publications.

I HAVE READ AND UNDERSTAND THIS RELEASE.

Signature: _____________________________ Date: ____________

Please fill out and send check payable to: Triple Threat Academy

Please send full payments to:

Triple Threat Academy   1271 Washington Ave #623   San Leandro, CA 94577