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Berwyn Blazers FC Parental Waiver and Consent Form

 

As the parent or legal guardian of the child named below, I hereby give my full consent and approval for my child to participate as a team member in the sport designated below.

 

I understand that there are certain risks of injury inherent in the practice and play of this sport, as well as in traveling and other related activities incidental to my child’s participation, and I am willing to assume these risks on behalf of my child. I hereby certify that my child is fully capable of participating in the designated sport and that my child is healthy and has no physical or mental disabilities or infirmities that would restrict full participation in these activities, except as listed below.

 

In addition to giving my full consent for my child’s participation, I do hereby waive, release and hold harmless the organization named below, its officers, coaches, sponsors, supervisors, and representatives for any injury that may be suffered by my child in the normal course of participation in the designated sport and the activities incidental thereto, whether the result of negligence or any other cause.

 

_________________________________________        _________________           

(Name of Child)                                                 (Date of Birth)

 

 

__________________________________  ___________________           ________               

(Street Address)                                                              (Town)                (State)

 

 

Please list any physical limitation (allergies, hearing, sight, etc.) ______________________________________________________________________________________________________

 

_______________________________________   _________________        

(Parent’s Signature)                                                         (Date)

 

 

                                                                                        Over….

Camp Medical Information and Release for Treatment

Date of Camp:_______________________________  

Child’s Name:_______________________________

Date of Birth:________________________  

Parent(s)/Guardian(s) Name:_____________________________________________________________  

Home address:___________________________________________________________________  Telephone #:______________________ Work #:______________________ Cell #:_________________  Secondary Contact Source in Case of Emergency: Name ______________________________________  Telephone #:______________________ Work #:______________________ Cell #:_________________

 

**** If my child needs medical treatment while participating at Berwyn Blazers FC Soccer Camps, I give my  permission for treatment to be given immediately.

 

Parent/Guardian Signature:________________________________ Date:________________________  Parent/Guardian Signature:________________________________ Date:________________________  Insurance Information  Insurance Co.:_______________________________

Member’s Name: ___________________________  Group :___________Policy #:________________ID#:______________________________Service Code: ___________________

Medical Information

 

1. If your child is presently taking any medication, please indicate Yes or No:________________ ____________________________________________________________________________________

 

2. Please indicate if your child is allergic to any medicine and list which one (s): __________

_______________________________________________________________________________________

 3. Please list any allergies:

___________________________________________________________________________  ___________________________________________________________________________________

 

4. Please list your child’s medical problems and/or significant injuries that the medical staff at  Berwyn Blazers FC Soccer Camps should be made aware of:____________________________________________________________________________________________________________________________________________________________

 

5. Date of your child’s last tetanus shot (if known):___________________________________________

 

Thank you for your cooperation in filling out this important emergency information form for Berwyn Blazers FC.