Dribling Soccer Academy

Dribbling Soccer Academy

Parent/Guardian Information
Parent's Name
First Last
Parent's Email
Parent's Phone
Address
Street Address Address Line 2 City State ZIP Code
Athlete Information
Child's Name
First Last
Child's Birth Year
Please select the year your child was born.
Born 2001-2009
Price:
Born 2010-2015
Price:
Gender
- Male
- Female
Emergency Information
Emergency Contact's Name
First Last
Emergency Contact's Relationship
Emergency Contact's Phone
Is the athlete prescribed an inhaler? If yes, please explain any instructions.
Does the athlete have any allergies, chronic illness, or medical conditions? If yes, please describe.
Informed Consent and Acknowledgement
I hereby give my approval for my child’s participation in any and all activities prepared by Fire Futbol Club during the selected camp. In exchange for the acceptance of said child’s candidacy by Fire Futbol Club., I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Fire Futbol Club and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected camp sessions.
In case of injury to said child, I hereby waive all claims against . including all coaches and affiliates, all participants, sponsoring agencies, advertisers, and, if applicable, owners and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in all sports activities, including basketball. Some of these injuries include, but are not limited to, the risk of fractures, paralysis, or death.
Medical Release and Authorization
I hereby give my approval for my child’s participation in any and all activities prepared by Fire Futbol Club during the selected camp. In exchange for the acceptance of said child’s candidacy by Fire Futbol Club, I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Fire Futbol Club and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected camp sessions.
As Parent and/or Guardian of the named athlete, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.
Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named athlete. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me.
Permission is also granted to the Fire Futbol Club and its affiliates including Directors, Coaches, and Team Parents to provide the needed emergency treatment prior to the child’s admission to the medical facility. Release authorized on the dates and/or duration of the registered season. This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.
Confirmation
BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.
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$0.00
Credit Card

Dribling Soccer Academy

Dribbling Soccer Academy

Parent/Guardian Information

Athlete Information

Emergency Information

Informed Consent and Acknowledgement

Medical Release and Authorization

Confirmation