Download and Print
Email To:Mail To:Empire Soccer Camps
PO Box 81 Lancaster, NY 14086 |
Or, Print and CompleteI understand that participation in the above event or activity could include actions or tasks which might be hazardous to the participant named above. By signing below, I assume any risk of harm or injury which might occur to the participant due to their participation in the event or activity. I release the organization of business named above from all liability, costs, and damages which might arise from participation in the above event or activity. I agree to accept financial responsibility for the costs related to this emergency treatment.
Health History: Please list any allergies, disease, and/or medications! (Conditions physicians should be made aware of. Please include a separate sheet if you need more room.) _______________________________________________________________________________________________________________________________
Date of last tetanus immunizations:__________________________ Parent or Guardian Health Insurance Company:_________________________________________ Policy No.________________________________ My child has had a physical recently and may participate in all activities. I hereby authorize directors of the Empire Consulting Services Soccer Camps to act for me according to their best judgment in any emergency if I cannot be contacted. I further agree that the Empire Consulting Soccer Services Soccer Camp should be held harmless from and indemnified against any and all liability, cost claims, loss or damage which it or they may occur as a result of an accident to my child. Waiver and Release: I acknowledge that Empire Soccer Consulting Services has made no representations concerning the operation, supervision, staffing, equipment, or any other aspect of the youth camp. I release and forever discharge Empire Soccer Consulting Services of and from all actions, causes of action, suits, damages, judgments, expenses, claims and demands whatsoever in law or in equity, that my child or I or our successors, assigns, heirs or distributes may have against Empire Soccer Consulting Services for any claim directly or indirectly arising from or out of my child’s attendance at the youth camp described in this registration. I understand that any camper who does not abide by the rules and regulations promulgated by camp is subject to dismissal without reimbursement or recourse. Parent/Guardian Signature_______________________________________________ Date___________________________________________ | ||
|
|
