Futlab Medical Form
Child's First Name *
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Child's Last Name *
Your answer
Parent's First Name *
Your answer
Parent's Last Name *
Your answer
Email Address *
Your answer
MEDICAL WAIVER *
:We, the undersigned, acknowledge and agree that attending or participating in sports may be hazardous and may result in injury. We further agree that we assume all risks of injury for ourselves, the child named above, and anyone else who comes with us to the premises incurred or suffered while upon the premises or as a result of using the facilities or equipment therein. We further, jointly and severally, as parents and legal guardians of the minor child, ourselves, and anyone else who comes with us to the premises, expressly agree to release, discharge, and agree to hold harmless and indemnify Soccer Genome LLC, The Genome Foundation and FUTlab, it’s owners, employees, coaches, agents, successors, assigns, affiliates, and anyone else associated with Soccer Genome LLC, The Genome Foundation and FUTlab from any and all claims, demands or damages whatsoever, whether developed or undeveloped, known or unknown, anticipated or unanticipated, have, now or in the future, including, but not limited to any all claims, demands or damages for negligence, personal injury and/or loss, theft or destruction of personal property. It is our intention that this release be as broad as North Carolina law allows releases of this sort to be. We further, jointly and severally, as parents and legal guardians of the minor child, ourselves, and anyone else who comes with us to the premises, expressly agree to release, discharge, and agree to hold harmless and indemnify the individuals, employees, coaches, owners of Soccer Genome LLC, The Genome Foundation and FUTlab from any and all liability, claims or demands arising from the minor child as a result of the minor child’s participation in the Program and/or being transported to or from the same, which transportation we hereby authorize. In addition, we do hereby authorize, Soccer Genome LLC, The Genome Foundation and FUTlab coaches and staff, after a reasonable attempt has been made to reach a parent or guardian to obtain consent, or if sound medical practice decrees that there is not time to make such an attempt, to consent to any x-ray examination, anesthetic, medical or surgical diagnosis or treatment, and hospital care, to be rendered to the minor child under the general or special supervision and on the advice of any physician or surgeon duly licensed to practice and do consent to any x-ray examination, anesthetic, dental or surgical diagnosis or treatment and hospital care, to be rendered to the minor child by any dentist duly licensed to practice. We further agree to save, hold harmless, and indemnify Soccer Genome LLC, The Genome Foundation and FUTlab, its owners, employees, coaches, agents, successors, assigns, affiliates, and anyone else associated with Soccer Genome LLC, The Genome Foundation and FUTlab from any and all claims, demands, damages, including cost, interest and attorneys’ fees which they may suffer or incur as a result of any claims by me, anyone who comes with me to the premises, or related entities, and/or result of any claims, demands or lawsuits arising out of my actions or those of anyone who comes with me to the premises. PLEASE SIGN YOUR NAME BELOW IF YOU AGREE TO THESE TERMS
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