| Name: |
| Address:
City: State/Zip
email: |
| Male or Female:
D.O.B. |
| Home # (
)
Work # ( )
EMERGENCY # ( ) |
| Cost $120:00
Boyd County KY, June 9-11, 2008
Team Camp (Name) _______________________________________________________________________________________
|
|
MEDICAL RELEASE FORM
I certify that my child is medically qualified to attend the
Technical Soccer Clinic and I hereby authorize the Staff to act for me according
to their best judgment in any emergency requiring medical attention. I give
permission for a physician and/or hospital emergency room to administer
necessary care. I waive and release the employees of Technical Soccer Clinics
LLC from all liability for any injuries and illness incurred while at clinic.
Furthermore, I agree to give permission for TSC to use any photos etc. gathered
during camp/clinics for promotional purposes.
Parent or Guardian's Signature Date:
/
/ 08 |
| Present Health (any medication)
|
| Past injuries |
| Drug sensitivities
Allergies |
| Insurance Company
Tel# |
| Group # ID/Policy # |
| Insured's Name and SS# |