Nellya Fencers:

Summer Fun Begins with Fencing

Application for Summer Programs for Beginners
To enroll, please complete this registration form and mail to the address at the bottom of the page. Please mail early in order to guarantee a space for your child. Class size is limited and we try to group children by age. Each session is $145. A $25 non-refundable deposit is required to hold a space. Camp fee is due one week prior to start of each session. Payment may be made by check or credit card. Please make checks payable to Nellya Fencers, Inc.

__ Check enclosed __ Credit Card: __ Visa __ MasterCard

Cardholder’s Name: (please print) _____________________________________

Card #:_____________________________Expiration Date:_________________

Signature:________________________________________________________

Address:__________________________________________________________

Phone#:__________________________________________________________

Today’s date:_____________________________________________________

Participant’s Name:_______________________________________________

__ Boy   __ Girl     Date of Birth:___________________    T-shirt size:____

Address:_________________________________________________________

Home phone:_______________Cell:_______________E-mail:______________

Parent/Guardian Name:_____________________________________________

Home phone:_______________Cell:_______________E-mail:______________

Please check desired session or sessions:

Waiver: I hereby waive and release all rights and claims for damages I may have against Nellya Fencers, Inc., the United States Fencing Association, the officials, managers, sponsors and other participants from any and all liabilities arising from illness, losses, injuries or damages I may suffer as a result of my participation in the Nellya Fencers Summer Fun Fencing Program. I understand that participation in the sport of fencing carries a risk to me of serious injury. I attest and verify that I am physically fit and prepared for strenuous physical activity. I further waive all rights to any photographs, videotapes, or any other recording of this event for any purpose.

Signature (if under 18, parent or guardian must sign):__________________________________

Consent for Medical Treatment: I understand that participation in the sport of fencing carries a risk to me of serious injury. I give my consent to representatives of Nellya Fencers, Inc. to obtain medical care from physicians, clinics or hospitals for any illness and/or injury that could arise during Nellya Fencers Summer Fun Fencing Program.

Emergency Contact: ______________________Phone:___________________

Signature (if under 18, parent or guardian must sign):__________________________________

Nellya Fencers, Inc.

1530 Carroll Drive NW, Suite 104, Atlanta, Georgia 30318 - (404)603-3600
info@nellyafencers.com