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NSR Boulder Camp Registration Form
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NSR Boulder Camp
Limited Spots: 3 of 8 filled
NSR Boulder Camp -
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Participant Last Name
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Street Address (w/Apt#)
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District of Col.
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Newfoundland and Labrador
Prince Edward Island
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Emergency Contact Name
Custom Camp Jersey included in camp fees.
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www.rocketscience.com for sizing chart
IMPORTANT - When you are on the USAT Site, you might be given a 4 digit CLAIM code for your account. This is
NOT YOUR LICENSE NUMBER
Do NOT use the 4 digit code on here. You must continue the USAT process of claiming your account until you have the option to get a license code ( this should be a 9 or more digit code).
Click here to purchase an ANNUAL Membership or One-Day License (aka. EVENT Membership) from USAT
REMEMBER to copy the USAT Code after your purchase so you can paste it below
Do NOT use the 4 Digit claim code from USAT, your USAT Lisc. will be more then 4 digits!
of your USAT License
One-day License (ADULT ONLY)
Enter your USAT annual membership or one-day license
Negative Split Racing activity, and willingly agrees to accept NEGATIVE SPLIT RACING SPORTS PROGRAM PARTICIPATION AGREEMENT Negative Split Racing organizations and Negative Split Racing organization participants may not engage in hazing activities. Hazing is defined as any action or situation that recklessly or intentionally endangers the mental or physical health or safety of a member or that willfully destroys or removes public or private property for the purpose of initiation or admission into or affiliation with, or as a condition for continued membership in any recognized member organization. Consumption of alcohol is prohibited during all Negative Split Racing activities, regardless of the age of the participants. Non-prescribed drugs, performance enhancing drugs, or any other substances that might be dangerous or detrimental to the participant’s health, or performance as a member of this organization are also prohibited. All Negative Split Racing Program participants have an obligation to refrain from actions and behavior that may jeopardize themselves or other Negative Split Racing Program participants. The Negative Split Racing Program reserves the right to remove participants from the program for actions/behavior that are deemed dangerous to themselves and/or other Negative Split Racing members. By accepting this agreement, the Negative Split Racing member understands the above regulations, and has agreed to conduct himself/herself in a safe and prudent manner at all times while participating in Negative Split Racing activities. NEGATIVE SPLIT RACING PROGRAM RELEASE OF ALL CLAIMS In consideration of the Negative Split Racing Group providing instruction and guidance to me, attempting to further my knowledge, and permitting me to participate in the Group, I ACCEPT and hereby agree to the following: I hereby covenant not to bring any action legal, equitable, or otherwise, or to make any claim of any nature whatsoever against Negative Split Racing, Rachel Jackson, Dawn Bauerle, David Bauerle, Jeff McAlister, Warren Durham, its employees, agents, the Group and its instructors, representatives and any other persons involved with the Group’s activities, either directly or indirectly, for any personal injury or injuries, including death or property damage which I or others might sustain in engaging in the Group’s activities necessarily or incidentally associated therewith. 1. I do hereby release and further discharge Negative Split Racing, its employees and agents, and the Group instructors, representatives and any other persons, either directly or indirectly, of any responsibility or liability of any nature to me for any personal injuries, death or property damage which I may suffer or incur either directly or indirectly as a result of my participation in the Group’s activities. 2. I MAKE THESE COVENANTS, RELEASE AND WAIVERS KNOWINGLY AND VOLUNTARILY WITH FULL KNOWLEDGE OF ANY EXISTING DANGERS IN TRAINING, PRACTICING, PLAYING, TRAVELING AND ENGAGING IN ANY OTHER GROUP ACTIVITIES; WHICH DANGERS I HEREBY FURTHER EXPRESSLY VOLUNTARILY ASSUME. 3. I further make these covenants, releases, and waivers to bind myself, my executors, heirs, administrators and assigns to the fullest extent. 4. I do execute this Release with the intent to be legally bound hereby for myself and on behalf of my heirs, administrators, executors and assigns. Print Name ______________________________________ Signature ________________________________________ Email ____________________________________________ Date ____________________________________________ NEGATIVE SPLIT RACING SPORTS PROGRAM ASSUMPTION OF RISK Negative Split Racing involves strenuous physical activity. Health professionals recommend that all participants complete a physical exam or have a doctor’s approval prior to beginning any exercise program and strongly urge all participants over the age of 45 to have a graded exercise test prior to beginning any exercise program. By accepting this agreement, one understands the importance of securing a physician’s approval of the participation in Negative Split Racing activities prior to participation in those activities. Participation in Negative Split Racing involves inherent risk. Possible injuries include, but are not limited to, contusions, muscle strains and sprains, broken bones, lacerations, cardiac malfunction, head, neck, and back injury, paralysis, drowning (in water activities), and death. By accepting this agreement, one understands that he/she should asses his/her physical condition and the possibility of injury. By accepting this agreement, one understands that he/she is fully responsible for any and all medical expenses that he/she might incur as a result of his/her participation in any Negative Split Racing activities. Participation in any Negative Split Racing Sports Program activity is contingent on proof of valid medical coverage. By accepting this agreement, one certifies that he/she has adequate medical insurance coverage that will cover any and all medical expenses resulting from his/her participation in any of the Negative Split Racing activities. By accepting this agreement, one understands that any travel conducted in conjunction with Negative Split Racing is voluntary and discretionary. Negative Split Racing DOES NOT ASSUME ANY LIABILITY FOR SUCH VOLUNTARY TRAVEL. By accepting this agreement, one has read this document and fully understands the risks involved with participation in any and assume those risks.
Read through the agreement
I have read and agreed to the waiver
Is the participant 18 or older?
18 or older
Parent or Legal Guardian’s Signature - By providing your electronic signature you agree that you have the authority to register these participants and agree to the waiver(s) for them as their parent or legal guardian.
If registering a child under 18, you are consenting to the collection of the child's information that you are providing for the purposes of registration.
Discount or Tracking Code
Do not COPY & PASTE the code, please type it into this field.
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Credit Card #
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Negative Split Racing
4120 Creekhollow Dr, Carrollton, TX
click the "pay now" button to submit your order then send a check to (or pay in person at) the address above.
1. Venmo the total amount to the Phone #:
2. Make sure you enter the code,
in "What's it for".
3. Click the "pay now" button.
Enter a Check Number
Enter a Check Amount
Send email receipt to the participant
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