Date: child): minor (if Parent/Guardian or Participant of Signature

I hereby assert that I fully understand and agree to these waivers and agreements. and waivers these to agree and understand fully I that assert hereby I

this event/program without compensation to me, my heirs, executors, agents and/or administrators. administrators. and/or agents executors, heirs, my me, to compensation without event/program this

advertisement or television coverage, whatsoever, of this capacity in any manner incidental to participation in in participation to incidental manner any in capacity this of whatsoever, coverage, television or advertisement

, sponsor sponsor , documentary official any in appear to child me/my of picture or likeness the allow I (4)

son, daughter or ward, is physically able to participate in the above activity(ies). above the in participate to able physically is ward, or daughter son,

that would keep the participant from taking part in the activity(s) and I accept responsibility that I and/or my my and/or I that responsibility accept I and activity(s) the in part taking from participant the keep would that

I hereby represent that the above participant is in good physical condition and has no disease or injury injury or disease no has and condition physical good in is participant above the that represent hereby I (3)

any injury or damages or claims to person or property resulting from the above-mentioned participation. above-mentioned the from resulting property or person to claims or damages or injury any

of, traveling to or from, and participation in the activity(s), and I hereby agree to hold the LFUCG harmless for for harmless LFUCG the hold to agree hereby I and activity(s), the in participation and from, or to traveling of,

whatsoever which may arise as a result of or in connection with, association or entry into in and/or arising out out arising and/or in into entry or association with, connection in or of result a as arise may which whatsoever

forever discharge the LFUCG from any and all claims, demands, damages, or injuries or causes of action action of causes or injuries or damages, demands, claims, all and any from LFUCG the discharge forever

legally bound, do hereby for myself, my heirs, executors, and administrators, do hereby waive, release and and release waive, hereby do administrators, and executors, heirs, my myself, for hereby do bound, legally

In consideration of the entry of me/my child into the Parks and Recreation activity(s), I, intending to be be to intending I, activity(s), Recreation and Parks the into child me/my of entry the of consideration In (2)

Recreation activity(s). activity(s). Recreation

whatsoever for any injury or damages which may result to me or my child from participation in a Parks and and Parks a in participation from child my or me to result may which damages or injury any for whatsoever

out of my/his or her participation in the above activity(s) and that the LFUCG assumes no responsibility responsibility no assumes LFUCG the that and activity(s) above the in participation her or my/his of out

I understand and agree that I or my child hereby voluntarily assumes any risk of injury that may arise arise may that injury of risk any assumes voluntarily hereby child my or I that agree and understand I (1)

WAIVER AND RELEASE AGREEMENT: AGREEMENT: RELEASE AND WAIVER

Date: Parent/Guardian: of Signature

Recreation camp or bus stop. bus or camp Recreation

WALKER RELEASE: WALKER My child is a walker and has permission to walk to and from the Division of Parks and and Parks of Division the from and to walk to permission has and walker a is child My

Date: child): minor (if Parent/Guardian or Participant of Signature

or ward, is physically able to participate in the above activity(s). above the in participate to able physically is ward, or

activity(s) covering medical and dental expenses. I further accept responsibility that I and/or my son, daughter daughter son, my and/or I that responsibility accept further I expenses. dental and medical covering activity(s)

I understand that I am responsible for any costs incurred due to injuries received in participating in the above above the in participating in received injuries to due incurred costs any for responsible am I that understand I

injuries or illnesses incurred while participating in the above activity(s). activity(s). above the in participating while incurred illnesses or injuries

authorization for any surgical procedure. Also, I waive and release the LFUCG from any and all liability for any any for liability all and any from LFUCG the release and waive I Also, procedure. surgical any for authorization

made to notify the parent/guardian/named emergency contact of the participant in or to grant any additional additional any grant to or in participant the of contact emergency parent/guardian/named the notify to made

LFUCG, if advance care (x-rays, tests, etc) is required. It is understood that every reasonable attempt will be be will attempt reasonable every that understood is It required. is etc) tests, (x-rays, care advance if LFUCG,

in any designated Parks and Recreation activity. I authorize admission to any hospital designated by by designated hospital any to admission authorize I activity. Recreation and Parks designated any in

daughter, or ward and/or to treat me/my child for any injury/illness that I/he/she sustains during participation participation during sustains I/he/she that injury/illness any for child me/my treat to and/or ward or daughter,

act for me according to their best judgment in an emergency requiring medical attention for me or my son, son, my or me for attention medical requiring emergency an in judgment best their to according me for act

and the agents or employees of its Division of Parks and Recreation, collectively referred to as “LFUCG”), to to “LFUCG”), as to referred collectively Recreation, and Parks of Division its of employees or agents the and

County Government (its agents, employees, representatives, elected or appointed officials or designees designees or officials appointed or elected representatives, employees, agents, (its Government County

MEDICAL CONSENT AGREEMENT AND RELEASE: AND AGREEMENT CONSENT MEDICAL I hereby authorize the Lexington-Fayette Urban Urban Lexington-Fayette the authorize hereby I

THIS SECTION MUST BE COMPLETED AND SIGNED FOR PARTICIPATION FOR SIGNED AND COMPLETED BE MUST SECTION THIS

Lexington, Kentucky Lexington, Street Upper North 545 Clinic and Roach Sanford l l

Cheerleading Clinic Cheerleading

and Sanford Roach Basketball Basketball Roach Sanford

Sanford Roach

T-shirts will be given to the FIRST 200 youth who Basketball and register for camp!

Session 1 (Co-Ed Basketball): 9 am-12 pm / July 22 - 26 (Ages 11 - 16) Cheerleading Session 2 (Co-Ed Basketball): 1-4 pm / July 22 - 26 (Ages 11 - 16) Session 3 (Cheerleading): 9 am-12 pm / July 29 - August 2 (Ages 7 - 14) Session 4 (Co-Ed Basketball): 1-4 pm / July 29 - August 2 (Ages 6 - 10) Clinic Sanford Roach Basketball and Cheerleading Clinics Please enroll me in the camp for the sessions checked. This application APPLICATION must be completed in full. All information will be kept confidential. Please FOR OFFICE USE ONLY mail application form no later than July 8, 2019 to: Sanford Roach Basketball & Cheerleading Clinic DATE:______545 North Upper Street Lexington, KY 40508 SESSION:______

Session 1 (Co-Ed Basketball): 9 am -12 pm / July 22 - 26 (Ages 11 - 16) Can your child leave the premises Session 2 (Co-Ed Basketball): 1pm - 4 pm / July 22 - 26 (Ages 11 - 16) at lunch time? (Ages 11-16) Session 3 (Cheerleading): 9 am -12 pm / July 29 - August 2 (Ages 7 - 14)  YES  NO Session 4 (Co-Ed Basketball): 1pm - 4 pm / July 29 - August 2 (Ages 6 - 10) Lunches will not be provided. The basketball clinic is open to youth ages 6-16 and the cheerleading clinic is You need to bring your snack/ open to those youth ages 7-14. All sessions will be held Monday through Friday lunch with you at the Dunbar Community Center, 545 North Upper Street.(859) 288-2955

PLEASE PRINT Name______Age ______Shirt Size______Address______City______State______ZIP______Grade (as of 9/2019)______School ______Birthdate______Sex_____ Height______Weight______Name of Parent/Guardian______Place of Employment______

Address of Parent/Guardian ______Phone_____/______Street City State ZIP E-mail Address ______EMERGENCY CONTACT AND CHILD RELEASE AUTHORIZATION (IF PARENT/GUARDIAN LISTED ABOVE CANNOT BE REACHED-MUST PROVIDE AT LEAST ONE CONTACT) Name______Relationship to Child______Phone ______Name______Relationship to Child______Phone ______Name______Relationship to Child______Phone ______Note: We cannot release your child to anyone other than the parent(s)/guardian(s) named above or the persons listed on this form. Individuals should be prepared to show identification. MEDICAL INFORMATION List any medical/physical limitations/precautions (food/insect/environmental allergies, frequent exhaustion, recent surgery, accidents etc.): List any medications the child will take during camp time: If medication is to be given at camp, please provide the following information: (Dosage and time to be given must be marked on the original medicine container sent to camp.) Name of Medication Dose (# pills, etc.) Exact time given

Our camps do not provide medical/health insurance. Campers are strongly encouraged to have their own insurance. WELCOME TO THE How you can help the Clinics SANFORD ROACH BASKETBALL AND CHEERLEADING CLINIC! The Sanford Roach Basketball and Cheerleading Clinic is the new name for the S.T. Roach Basketball I would like to take this opportunity to welcome you to the Sanford and Cheerleading Clinic. If you would like to make Roach Basketball and Cheerleading Clinic. These clinics are designed to introduce basketball and cheerleading fundamentals, a donation to the clinic please make any checks to: as well as instill a sense of teamwork and develop sportsmanship Sanford Roach Basketball and Cheerleading Clinic. in youth ages 6-16. The organized activities within these clinics All donations are used specifically for the clinic. will be coordinated by Donna Wilson (Retired Head Cheerleading Thanks for your support. Coach at Henry Clay High School) and Roy Booker (Youth Service Coordinator at Crawford Middle School). Sanford T. Roach As a former teacher and coach at Dunbar High School, S. T. Roach S. T. Roach , now deceased,served as a Teacher and recognized the benefits that athletics offered to the development Coach at Bates High School in Danville and Dunbar and self-esteem of youth. He became concerned about the High School in Lexington for 25 years. During his 25 availability of summer basketball and cheerleading clinics to all members of the community. This concern motivated him to initiate years as a Basketball Coach, he compiled a record a program that would offer a solution to this need. of 610 wins, 167 losses, won the KHSAL State Title in 1948 and 1950 and took Dunbar to the Sweet THESE CLINICS ARE FREE TO ALL PARTICIPANTS! Sixteen six times. Coach Roach was a member of It is our hope that you will enjoy your time with us. the KHSAA. He was inducted in to the KSU Kentucky Athletic Hall of Fame, Kentucky Athletic Hall of Jacquelyn French Fame and National Athletic Hall of Fame. He was a Recreation Manager retired Principal, School Administrator and a Former Division of Parks and Recreation (859)288-2955 Assistant to several Mayors of Lexington.