2012 july 4th celebration week
DESCRIPTION
berkeley hall clubTRANSCRIPT
2012 July 4 Weekend Celebration July 2-6, 2012
TH 2012 July 4 Week Celebration :: July 1-6S C H E D U L E O F E V E N T S
Dear Berkeley Hall Membership,
We’ve planned a full week of activities for the entire family at the 4th Annual
Signature 4th of July Week Celebration. In addition to a stunning fireworks
display on Wednesday, July 4th, we are planning several complimentary events
for the entire family. Be sure to sign up for one or all of the golf events & clinics,
laser tag at the Fazio, member mingling with summer brew & wine sampling, family
pool parties, tennis clinics and a 5K Fun Run/Walk for both Adults and Children alike.
We are pleased that you are interested in participating in this celebration and hope
the events scheduled will be enjoyable and will create an atmosphere of friendly
competition and fellowship.
Please refer to this booklet for the itinerary and general information on each event.
All reservations must be secured through Concierge Services. If there is anything
we can assist you with, please do not hesitate to ask or call (843)815-8494. We look
forward to hosting this very special signature event for every member of Berkeley Hall.
Regards,
Adrian Morris
General Manager/Chief Operating Officer
Sunday, July 1st
6-8pm Sunday Pasta Night
Come and create your own Italian pasta dish, then have it prepared by your own Chef.
Design your dish with a selection of ingredients, summer vegetables, homemade sauces
and several pastas along with salad and desserts. A great family night for all ages.
Reservations: Tap Room, 843.815.8428
Location: Mixed Grille
Price: $15.95++ adults, $8.95++ children
Monday, July 2nd
9-11am Guided Kayak Tour
Our 2-hour kayak nature tour offers both a great introduction to kayaking and an
educational nature tour on one of the most pristine rivers in South Carolina. A trained
interpretive naturalist guide will lead your journey up the Okatie River. No experience
necessary and chilled bottled waters are included.
Reservations: Concierge Services, 843.815.8494
Location: Meet at the River Park Dock
Price: $25.00 per person
Monday, July 2nd (continued)
9:30-3pm July 4th Week ~ Special Kids Day Camp Two-day July 4th Week Kids Camp for ages (6-10) years. Events include summer pottery,
tennis, golf, swimming and a special Slip-n-Dip slide at the Spa & Fitness Center. Lunch
and snacks will be provided throughout the day. Be prepared to be out in the summer heat,
cooling off in the swimming pool and simply having a blast by enjoying all of the amenities
that Berkeley Hall has to offer. Children, grandchildren & friends more than welcome.
Note: Children must be able to swim well to participate in Berkeley Hall Day Camp.
Reservations: Concierge Services, 843.815.8494
Location: Ladies Locker Room, Lounge
Price: $50.00 per child, per day
10-11:30am Complimentary Tennis Clinic ~ Adults & ChildrenCome and enjoy an hour and half of tennis, beginning at 10:00 am. The clinic will include
active drill situations based on the player’s levels in a fun environment. You will hit plenty
of balls and enjoy time with fellow members and guests. There will be supervised play
based on the skill levels. Come on out, we look forward to seeing you on the courts.
Instruction divided between Adult and Children.
Reservations: Spa & Fitness Center, 843.815.8985
Location: Spa & Fitness Center
Price: Complimentary
Cruise Times: 4pm & 6pm Guided Pontoon Boat Cruises of the Scenic Okatie River Take a relaxing guided boat cruise up the Okatie River and enjoy the panoramic views of
the marshes. From the cacophony of wildlife abounds from snapping shrimp to the flights
of the marsh wren to the playful dolphins, all can be viewed during this cruise.
Reservations: Concierge Services, 843.815.8494
Location: Meet at the River Park, Dock
Price: $25.00 per person, includes Cooler of Sodas and Waters
$15.00 per person, children 12 and under
SOLD OUT
Monday, July 2nd (continued)
6pm Goofy Golf Games, Mobile Laser Tag & an Old Fashioned Cookout at the Learning CenterCasual summer evening at the Learning Center. Several Goofy Golf Stations will be set up
through the Learning Center to test your game to win a variety of prizes and challenges.
~ Hit to the Floating Pool in the Pond, 3-Hole Putting Challenge, Longest Drive Testing ~
Chef Tom will have an old-fashioned cookout and the Fazio Bar will be open with chilled
libations and seasonal cocktail specials. Test your skills with your family while playing
Mobile Laser Tag complete with inflatable buoys and obstacles while playing “capture the
flag” team game. (Ages 8 & Up)
Old Fashioned Cookout Menu
Cilantro Pico de Gallo & Queso Fresco, Tortilla Chips
Chilled Salads, Tossed Garden Greens, Ranch or Balsamic Dressing
Broccoli & Carrot, Macaroni & Caramelized Ham
Off the Flaming Grill:
Flame Grilled Hamburger, Hot Dogs, Chicken Breast and Veggie Burgers with appropriate trimmings
Assorted Fruits, Red, White & Blue Cupcakes, Rice Krispy Treats
Reservations: Concierge Services, 843.815.8494
Location: Fazio, Learning Center *Back up in the Clubhouse
Price: $15.95++ adults, $8.95++ children (ages 4-11)
NEW!
Tuesday, July 3rd9:30-3pm July 4th Week ~ Special Kids Day Camp Two-day July 4th Week Kids Camp for ages (6-10) years. Events include summer pottery,
tennis, golf, swimming and a special Slip-n-Dip slide at the Spa & Fitness Center. Lunch
and snacks will be provided throughout the day. Be prepared to be out in the summer heat,
cooling off in the swimming pool and simply having a blast by enjoying all of the amenities
that Berkeley Hall has to offer. Children, grandchildren & friends more than welcome.
Note: Children must be able to swim well to participate in Berkeley Hall Day Camp.
Reservations: Concierge Services, 843.815.8494
Location: Ladies Locker Room, Lounge
Price: $50.00 per child, per day
Cruise Times: 10am, 4pm, & 6pm Guided Pontoon Boat Cruises of the Scenic Okatie River Take a relaxing guided boat cruise up the Okatie River and enjoy the panoramic views of
the marshes. From the cacophony of wildlife abounds from snapping shrimp to the flights
of the marsh wren to the playful dolphins, all can be viewed during this cruise.
Reservations: Concierge Services, 843.815.8494
Location: Meet at the River Park, Dock
Price: $25.00 per person, includes Cooler of Sodas and Waters $15.00 per person, children 12 and under
10-11am Complimentary Adult Golf Clinic, Learning CenterComplimentary Clinics for adults will include swing instruction, exciting prize challenges,
and valuable information to better your game. Let our experienced golf professionals
enhance your golfing experience with great instruction and drills to better your game this
summer.
Reservations: Concierge Services, 843.815.8494
Note: Please identify Adult participant
Location: Meet at the Learning Center Practice Tee
Price: Complimentary
SOLD OUT
Tuesday, July 3rd (continued)
11am Cold Blood Adventures Reptile ShowVery special show to see rare and rescued reptiles. Brian Nettles will share his current
collection of rescued and very friendly reptiles while providing education about each
one, their habitats, feeding, mating and day to day life. Come by and see the show.
Limited to 25 children.
Reservations: Concierge Services, 843.815.8494
Location: Meet in the Berkeley Room
Price: Complimentary
Note: An adult must accompany a child and/or siblings
1pm Complimentary Children’s Golf Clinic, Learning CenterComplimentary Clinics for children will include simple swing instruction, exciting prize
challenges, and valuable information to better your game. Let our experienced golf
professionals enhance your golfing experience with great instruction and drills to better
your game this summer.
Reservations: Concierge Services, 843.815.8494
Note: Please identify Child & age of participant
Location: Meet at the Learning Center Practice Tee
Price: Complimentary
Tuesday, July 3rd (continued)
6-8pm MemberMingle&SummerBonfireattheRiverPark *Royal Restrooms located at the River Park during July 4th Week
Brew Sampling & Wine Tasting ~ Glow Cups for All DJ & Karaoke from HH Entertainment Kidzplay ~ Sno Cones, Feather Extensions & Tattoos
We’ll mix and mingle at the River Park while sampling some of the Coolest Summer
Brews and crisp White Wines. Try our collection of refreshing summer brews that are still
packed with enough flavor to hold the attention of the most discerning of beer connois-
seurs. We’ll have an assortment of tasty hors d’oeuvres and pub snacks to compliment our
brews.
Reservations: Concierge Services, 843.815.8494
Location: Meet at the River Park, Patio
Price: $15.00++ per person (adults & children)
Member Mingle & Summer Brew Tasting
(8) Summer Favorite Brews in Glow Cups
(6) Cool Summer Wines
Non Alcoholic Beverages: Sodas, Lemonade, Blue Hawaiian & Water
Lettuce Wraps of Tomato, Carrot, Cucumbers and Celery
Carolina Cabbage Slaw, Jambalaya Pasta Salad and
Cherry Tomato, Mozzarella & Pepperoncini Picks
Pulled Smoked Turkey, Cranberry BBQ Sauce, Miniature Rolls
Beer Battered Cod, Chicken Tenders, and Tater Tots
Snow Cones, S’mores, Frosted Red, White & Blue Star Cookies
Strawberry Dip & Summer Fruits
Wednesday, July 4th
7am Liberty Bell 5K ~ Registration
8am Liberty Bell Adults 5K Fun Run, Walk, or Bike
9am Liberty Bell Children’s Fun Run, Walk
Following Awards Presentation & Continental at the Clubhouse
Continental Menu ~ Double Blueberry Muffins, Sliced Banana Nut BreadSummer Fruits of Orange & Grapefruit Wedges, Granola & Kashi BarsBottled Waters and Gatorades
Race DescriptionThe 5K fun race will begin at front of the clubhouse and throughout the property. The
course race will differ from previous courses but finish up at the Grand Mall where
friends and family can cheer loved ones on. We will have a mobile and stationary
water station at the halfway point along the course route.
RegistrationPlease submit the attached registration form by fax to 843.815.4630 or drop off at
the Spa and Fitness Center. Registration will close at 12 pm on Monday, July
2nd….please do register in advance to ensure all participants receive a race
t-shirt.
Adults & Children’s AwardsIndividual Awards will be presented to the top participant in each age division, as well as
the overall winner both male and female. Top (3) places will be awarded for the children’s
race.
Reservations: Spa & Fitness Center, 843.815.8985
Email: [email protected]
Location: Meet at the Clubhouse, Front Entrance
Price: $18.00 per adult, $12.00 per child
Wednesday, July 4th (continued)
Cruise Times: 10am & 4pm Guided Pontoon Boat Cruises of the Scenic Okatie River Take a relaxing guided boat cruise up the Okatie River and enjoy the panoramic views of
the marshes. From the cacophony of wildlife abounds from snapping shrimp to the flights
of the marsh wren to the playful dolphins, all can be viewed during this cruise.
Reservations: Concierge Services, 843.815.8494
Location: Meet at the River Park, Dock
Price: $25.00 per person, includes Cooler of Sodas and Waters $15.00 per person, children 12 and under
Wednesday, July 4th (continued)
11am-4pm Berkeley Hall Pool Party & Cookout *Pool Only Open for Guests of the Grand Pool Party due to Pool Occupancy
Duo of Kizplay Slides ~ Pool Lawn, Patriotic Crafts JLK Events ~Music, Trivia, Whacky Pool Games & Challenges Teens vs Adults ~ Volleyball Game ~ 2 pmLet the games begin, join in the fun whether it’s testing your American Trivia knowledge,
testing your skills at one of our poolside challenges, we’ll have a favor and prize for ev-
eryone! DJ, Jami Bodie will return to provide everyone’s favorite tunes! Don’t forget to
take your buddy to the 27’ Roaring Rapids Slide and Pool alongside the Tropical Bounce
Slide and Pool…something for everyone in the family. We’ll have a shaded slide viewing
area for all to enjoy.
Reservations: Concierge Services, 843.815.8494
Note: Pool will be open only for Pool Party Participants (Age 4 & under Free)
Location: Spa & Fitness Center, Outdoor Pool
Price: $20.00++ Adults, $12.00++ Children includes Lunch, Favors, Slides & Prizes
(Pool Party) All American Lunch from 12-2 pm
Cool Salad Display ~ Sweet Corn, Black Bean & Tomato with Chips, Fruit Cocktail,
Green Salad, Firecracker Shrimp & Pasta, Albacore White Flake Tuna,
Miniature Bakery Croissants
Italian Hoagie ~ Pool Deck Beef Sliders or Kielbasa Sausage Chopped Onions, Pickles, Ketchup, Mustard, Soft Rolls, Condiments
Buffalo or Ranch Chicken Wings ~ Blue Cheese or Ranch DipClub Chips, Pretzels, Snack Bars
Frozen Sweets ~ Frozen Pops, Watermelon Wedges, Ice Cream Bars, Sno Cones
Iced Tea, Pink Lemonade, Iced Water (Member Charge Bar/Cocktails)
Wednesday, July 4th (continued)
All Day Flag Day Golf TournamentYou are cordially invited to participate in the Flag Day Golf Tournament. We hope
that you will join us for a round of fellowship and spirited competition. No summer
tournament would be complete without coolers of frozen towels as well as chilled
watermelon wedges to beat the summer heat. Following play we will offer an optional
American Lunch Cookout, not included in tournament fee. Players are encouraged to
make their own tee times via ForeTees for this event; entry fee will be collected on the 1st
tee prior to start for those who wish to participate.
Location: Check in to receive flag at the Practice Tee with a member of the
Professional Staff
Price: Entry fee will be $10.00 per player and will go towards prizes.
All Day Flag Day Golf Tournament
Format Individual Stroke Play
Course: North & South Golf Courses
Entries: Individual tee times may be made directly onto ForeTees on the
Berkeley Hall website or you may call the golf shop directly at
843.815.8444.
Wednesday, July 4th (continued)
6:30-9:30pm 4th Annual Berkeley Hall Patriotic Celebration
Low Country Cookout, Carnival & Fireworks ShowcaseFamily Check In & Photo Booth Printable for each Family
All Families will be asked to come through the front of the clubhouse to get their glow necklace & table assignments.
JKL Events will be here to take printable family fun photos at the Grand Entrance.
Full Service Bar Zones including Liquor, Beer, Wine & Sodas/Waters
Play Zone: Equalizer Bungee Competition, Basketball Sports Bounce House, Face Painting & Carnival Games
All Fan Interactive Basketball Sports Bounce House in which you can bounce, climb AND then slide!
Are you ready for this!!! Prepare yourself, you are about to have the time of your life! It is you versus your competitor, you both put on harness and are attached to a
Bungee. Ready, Set, Go...the first to get four ball in the basket wins. Sounds easy...not so much! It is as much fun to watch as it is to play.
Play Zone will include a visit from our most friendly clown & character guests.Be sure to test your skills at our Whacky Carnival Games.
Patriotic Evening Entertainment
Let JLK Events Celebrate with Music throughout the Decades, Dancing, Show Tunes and Patriotic Songs
Wednesday, July 4th (continued)
4th Annual Berkeley Hall Patriotic Celebration Grand Buffet
Refreshing Chilled Summer SaladsSweet & Sour Vegetable Salad
Chilled Marinated White & Green Asparagus, Herb Vinaigrette
Miniature Buffalo Mozzarella & Cherry Tomato Salad, Balsamic Reduction
Potato Egg Salad, Sweet Tri-Colored Cabbage Slaw, Greek Feta Pasta SaladMini Sweet Corn and Cheese Biscuits, Home-Style Rolls, Honey Butter
Southern Accompaniments Stewed Green Casserole, Macaroni & Cheese, Root Beer Baked Beans,
Sweet Corn on Cob with Butter Chips
Deep Fry StationCarolina Fried Chicken, Pickles, Corn Fritters and Cornmeal Fried Shrimp
Kids Fried Chicken Tenders
Spicy Remoulade, Creamy Tarter, Wild Honey Mustard
OfftheGrill~Beef&VegetableBrochettesorSwordfishSteaksPeppered Beef Brochettes, Vegetable or Swordfish Steaks in Lemon Caper Butter
In the SmokerWhole Smoked Hog and Butts, with Trio of BBQ Sauces
Grand Finale DessertApple Cinnamon Cobblers, Banana’s in Brown Sugar, Hot Fudge, Ice Cream & Toppings
Miniature Cookies, Fresh Berries, Shortcake Station, Sweet Watermelon
and Berkeley Chocolates
Reservations: Concierge Services, 843.815.8494
Location: Clubhouse, Grand Lawn
Table Assignments: Tables will be reserved by Family or Open Club Tables
Price: $58.00++ Adults, $35.00++ Children (Ages 4-11)
Thursday, July 5th9am-11am Adult & Child (3-Hole) Golf Tournament at the Learning CenterYou are cordially invited to participate in the Adult & Child Golf Tournament at the
Learning Center. We hope that you will join us for fun (3-Hole) Golf Tournament.
Families are encouraged to contact the golf shop to register for this special event.
Location: Check in to receive tournament instructions at the Learning Center with a member of the Professional Staff
Format: Par Three Challenge
Entries: Families are encouraged to contact the golf shop to register for this special event.
Cruise Times: 10am, 4pm, & 6pm Guided Pontoon Boat Cruises of the Scenic Okatie River Take a relaxing guided boat cruise up the Okatie River and enjoy the panoramic views of
the marshes. From the cacophony of wildlife abounds from snapping shrimp to the flights
of the marsh wren to the playful dolphins, all can be viewed during this cruise.
Reservations: Concierge Services, 843.815.8494
Location: Meet at the River Park, Dock
Price: $25.00 per person, includes Cooler of Sodas and Waters
$15.00 per person, children 12 and under
4pm Cold Blood Adventures Reptile ShowVery special show to see rare and rescued reptiles. Brian Nettles will share his current
collection of rescued and very friendly reptiles while providing education about each one,
their habitats, feeding, mating and day to day life. Come by and see the show. Limited to
25 children.
Reservations: Concierge Services, 843.815.8494
Location: Meet in the Berkeley Room
Price: Complimentary
Thursday, July 5th (continued)
11am-4pm Berkeley Hall Pool Party & Cookout *Pool Only Open for Guests of the Grand Pool Party due to Pool Occupancy
Duo of Kizplay Slides ~ Pool Lawn, Patriotic Crafts JLK Events ~Music, Trivia, Whacky Pool Games & Challenges Teens vs Adults ~ Volleyball Game ~ 2 pmLet the games begin, join in the fun whether it’s testing your American Trivia knowledge,
testing your skills at one of our poolside challenges, we’ll have a favor and prize for ev-
eryone! DJ, Jami Bodie will return to provide everyone’s favorite tunes! Don’t forget to
take your buddy to the 27’ Roaring Rapids Slide and Pool alongside the Tropical Bounce
Slide and Pool…something for everyone in the family. We’ll have a shaded slide viewing
area for all to enjoy.
Reservations: Concierge Services, 843.815.8494
Note: Pool will be open only for Pool Party Participants (Age 4 & under Free)
Location: Spa & Fitness Center, Outdoor Pool
Price: $20.00++ Adults, $12.00++ Children includes Lunch, Favors, Slides & Prizes
(Pool Party) All American Lunch from 12-2 pm
Cool Salad Display ~ Sweet Corn, Black Bean & Tomato with Chips, Fruit Cocktail,
Chicken Salad, Green Salad with Assorted Dressings
Deli Bar ~ Deli Meats, Sliced Breads & Rolls, Condiments
Grilled Chicken & Pineapple Kabobs, Peanut Butter & Jelly Squares
Club Chips, Pretzels, Snack Bars
Frozen Sweets ~ Frozen Pops, Watermelon Wedges, Ice Cream Bars, Sno Cones
Iced Tea, Pink Lemonade, Iced Water
Friday, July 6thGuided Pontoon Boat Cruises of the Scenic Okatie River Cruise Times: 10am, 4pm, & 6pm Take a relaxing guided boat cruise up the Okatie River and enjoy the panoramic views of
the marshes. From the cacophony of wildlife abounds from snapping shrimp to the flights
of the marsh wren to the playful dolphins, all can be viewed during this cruise.
Reservations: Concierge Services, 843.815.8494
Location: Meet at the River Park, Dock
Price: $25.00 per person, includes Cooler of Sodas and Waters
$15.00 per person, children 12 and under
10-11:30am Tennis Clinic & Round Robin ~ Adults & ChildrenCome and enjoy an hour and half of tennis, beginning at 10:00 am. The clinic will include
active drill situations based on the player’s levels in a fun environment. You will hit plenty
of balls and enjoy time with fellow members and guests. There will be a round robin mini
tournament based on skill. Come on out, we look forward to seeing you on the courts.
Note: Children will receive Clinic Instruction for the duration.
Reservations: Spa & Fitness Center, 843.815.8985
Email: [email protected]
Location: Meet at the Spa & Fitness Center, Rear Verandah
Price: $10.00 per participant
Note: Please identify Child (Age) or Adult (Level)
10-11am Complimentary Adult Golf Clinic, Learning CenterComplimentary Clinics for adults will include swing instruction, exciting prize challenges, and
valuable information to better your game. Let our experienced golf professionals enhance
your golfing experience with great instruction and drills to better your game this summer.
Reservations: Concierge Services, 843.815.8494
Note: Please identify Adult participant
Location: Meet at the Learning Center Practice Tee
Price: Complimentary
Friday, July 6th (continued)
3pm Stars & Stripes 9-Hole Twilight GolfJoin us for a relaxed, fun afternoon of 9-holes of golf with your golf buddies and their
guests. Entry fee will $5 per player and will go towards prizes. Normal guest fees apply.
Please register via ForeTees or by calling the golf shop at (843) 815-8444.
Reservations: Golf Shop, 843.815.8444
Location: South Course
Price: $5.00 per player
6-9pm 1st Friday Grill Nights & Lawn Games Guitarist: David Bohn
Our 1st Friday Grill Nights continue as a conclusion to the holiday week with Guitarist
David Bohn. We’ll have a few lawn challenges for those looking to test their outdoor game
skills.
Reservations: Concierge Services, 843.815.8494
Location: Clubhouse Verandah
Price: $17.00++ per person, $10.00++ children
1st Friday Grill Nights Stars & Stripes Menu
Crisp Greens, Cherry Tomatoes, Red Onions, Green Peppers, Cucumbers, Sweet Carrots,
Croutons, Parmesan Reggiano Cheese, Italian Vinaigrette & Creamy Blue Cheese
Sweet Grape & Fruit Salad Toss, Mediterranean Pesto Pasta Salad, Cilantro Cous Cous
Sirloin Steak with appropriate trimmings, Fresh Catch of Day, Grilled Chicken Breast, Baked Potato Station
Children’s Station: Spaghetti & Meatballs, Garlic Bread
Georgia Peach Cobbler, Vanilla Ice Cream, Chocolate Brownies
LIBERTY BELL 5K FUN RUN, WALK OR BIKE REGISTRATION FORM*
Name:
Member Name or Parent’s Name (if under 18 yrs of age):
Age: Gender:
Adult Shirt Size: ___Medium ___Large ___XL ___XXL
Child Shirt Size: ___Medium ___Large
5K Registration Fee: _____$18.00 Adults _____$12.00 Children**All Charges will be placed onto Member account.**
ACKNOWLEDGEMENT, WAIVER & RELEASE FROM LIABILITY WAIVER:I know that running a road race is a potentially hazardous activity. I should not enter and participate unless I am medically able and properly trained. I agree to abide by any decision of a race official relative to my ability to safely complete the run. I assume all risks associated with running in the Berkeley Hall Liberty Bell 5K Race on July 4th including, but not limited to falls, contacts with other participants, the effects of the weather, including high heat and humidity, traf-fic and condition of the road, all such risks being known and appreciated by me. Having read this release and knowing these facts and in consideration of your accepting my entry, I for myself and anyone entitle to my behalf, waive and release Berkeley Hall Club and any or all sponsors, con-tributors of the race, their agents, and any persons assisting with the race and their successors for all claims or liabilities of any kind arising out of participation in the race event though the liability may arise out of negligence or carelessness on the part of the person referred to in this waiver. I also grant permission for the use of any photographs, motion pictures, recordings or any other record of my participation in this event for any legitimate purpose. In the event that this race cannot be held on July 5th due to circumstances beyond the control of Berkeley Hall, e.g. unsafe weather conditions, the race will be canceled and will not be rescheduled for another date this year. Since the majority of the race – such as entry forms, awards, t-shirts, favors, occur prior to the race; entry fees may not be refunded.
( ) I hereby certify that I am (18) years of age or older, I have read this document; and I understand its contents.
( ) I am under the age of (18) years – my parent/grandparent/guardian has read and completed the waiver below.
Printed Name:
Signature: Date:
PARENT/GUARDIAN WAIVERFOR MINOR:
If the application is under 18 years of age, the parents or guardians must execute in addition
to the standard waiver above, the following waiver and consent.
The undersigned (parent/grandparent/guardian)
referred to as the parent and natural guardian or legal guardian of
(minor’s name)
does hereby represent that he/she is, in fact, acting in such capacity and agrees to save and
hold harmless an indemnify each and all parties herein named on this form and releases from
all liability, loss, cost, claim or damage whatsoever that may be imposed upon said releases
because of any defect in or lack of such capacity to so act and release said releases on behalf
of both of the undersigned.
CONSENT TO MEDICAL TREATMENT OF MINOR:I hereby authorize any duly authorized doctor, emergency technician, hospital or other medical facility to treat said minor for the purpose of attempting to treat or relieve any injuries received by said minor while he/she was a participant or observer in the event.
I authorize any licensed physician to perform any procedure which he/she deems advisable in attempting to treat or relieve any injuries or any related unhealthy conditions of said minor that he/she may encounter during any necessary operation.
I consent to the administration of anesthesia as deemed advisable by any licensed physician. I realize and appreciate that there is a possibility of complications and unforeseen consequences in any medical treatment, and I assume any such risk on the behalf of myself and said minor. I acknowledge that no warranty is being made as to the results or any treatments.
Parent/Grandparents/Guardian Signature:
Date: