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Sponsored by: |
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Soccer International, |
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DeRosario Soccer Academy 2008 Thanksgiving
Player Age: _______ Player Gender: M or F Mail completed form, along with payment to: DeRosarioSoccerAcademy c/o Lori Hibbett Player Information: Name: ______________________________________ Address: ___________________________________ City: ________________________ Zip: ________________ Email: ____________________________________ Parent and Medical Information: Mother/Guardian: ______________________________ Tele #: _____________________ Cell #_________________________ Email: ______________________________________ Father/Guardian: _______________________________ Tele #: ______________________ Cell #_________________________ Email: ______________________________________ Emergency Contact Name: _____________________________ Tele #: ______________________ Relation to this person:____________ Physician Name: ____________________________________ Physician Tele #: ______________________ Health Insurance Carrier: _______________________________ Policy #: ____________________ List all medical conditions: __________________________________________________________ List any medicine currently being taken: __________________________________________________________ As the parent or guardian, I give my approval to the above named player to participate in any and all of the activities of the camps including but not limited to practices, drills, games and any other activity associated with the clinic/camp/training. PLAYER AND PARENTS ASSUME ALL RISKS AND HAZARDS INCIDENTAL TO THE CONDUCT OF THE ACTIVITIES AND TRANSPORTATION TO AND FROM THE CLINIC/CAMP/TRAINING. I further release absolve, indemnify and agree to hold harmless Dwayne DeRosario, DeRosario Soccer Academy, the organizers, directors, sponsors, supervisors, coaches, facility, and administration and each of them from any claim, demand or action arising out of, or in any way related to the clinic/camp/training, including and not limited to any injury. In the event of an injury I authorize the staff to obtain any medical care or treatment deemed medically necessary. I HAVE CAREFULY READ THE ABOVE WAIVER AND RELEASE AND FULLY UNDERSTAND THIS IS A RELEASE OF LIABILITY AND I AGREE TO IT VOLUNTARILY. I also give permission to photograph the above participant and use those pictures in advertising material. My signature below, however made, is my acknowledgement that I have read and understand the above. Signature: __________________________________________ Date: _________________________ Printed name: ___________________________________ Make checks payable to Dwayne DeRosario. |
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