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Futsal 365 Academy

 Registration, Medical Release Form

www.futsal365academy.com  

732.580.2174

TODAY'S DATE: November 22, 2019

PARENTS APPROVAL AND MEDICAL RELEASE

I, the undersigned, in consideration for my voluntary participation in organized soccer, do hereby willfully acknowledge that my signature below attests to my understanding and agreement that: My player status will be kept in good standing. I will not compromise myself in such a way as to do harm to Futsal 365 Academy knowing that players may be dismissed from participation, with possible loss of payment or dues, for violent conduct or unsportsmanlike behavior on or off the field of play. I agree to pay for any and all damages to any property or indemnities caused by me willfully, negligently, or otherwise. Futsal is a physical, contact, sport that involves the risk of injury. I assume all risks and hazards associated with my participation in the sport. I am in proper physical condition to participate in soccer practices and games and have no illness, disease or existing injury or physical defect that would be aggravated by my participation. I will inform the coach or supervisor if this status changes. I further acknowledge that this risk may involve loss or damage to me or my property, including the risk of death, or other unforeseen consequences, including those which may be due to the unavailability of immediate emergency medical care. I will wear shin guards, properly-fitted and appropriate shoes, and other protective equipment (e.g., mouth-pieces), as provided by soccer rules, to all events. Futsal 365 Academy does not have personal injury insurance that covers my participation. Therefore, I should have a current, active, personal injury insurance policy in force, which covers my participation. Under any condition, I am responsible for any and all medical expenses arising from my participation, both in practices and games and while traveling to and from these events. I have the right and responsibility to inspect the equipment and facilities prior to events and, if I believe that anything may be unsafe, I will advise the coach or supervisor of the condition and may refuse to participate. Participation assumes consent. I authorize my photograph, picture or likeness, and voice to appear in any documentary, promotion (including advertising), social media, website, television, video, or radio coverage of Futsal 365 Academy, without compensation. I authorize that an unaltered copy of this form may be generated and given to the officers or directors of other organization in order to allow my participation in their soccer programs, if the form is required and I have requested to participate. I hereby release, waive liability, discharge, hold harmless, indemnify, and covenant not to sue, the United States Soccer Federation, US Youth Soccer, US Club Soccer, New Jersey Youth Soccer, US Youth Futsal, Futsal 365 Academy, the facility used by Futsal 365 Academy, their associated directors, administrators, officers, managers, employees, coaches, trainers, volunteers, sponsors and advertisers, and other agents, estates or executors, from any and all liability incurred in the conduct of, and my participation in, their soccer programs. This includes owners, lessors, and lessees of premises, municipalities, government agencies, successors, heirs, and assigns. I have completely read this document and fully understand its contents. I acknowledge that I have given up substantial rights by accepting this document and that I do so voluntarily. Checking the box below attests to this on behalf of myself and my executors, personal representatives, administrators, heirs, next-of-kin, successors, and assigns.

Parent's Agreement: 

I Agree

Please select who will be participating...
Minor
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First Player's Name

First Name*

Last Name*

Phone*
First Player's Date of Birth*
First Player's Information

Father's Name:

Phone:

Mother's Name:

Phone:

In an emergency when parents cannot be reached, please contact:


Name:

Home Phone:

Work Phone:

Medical Information


Allergies

Other medical conditions

Player's Physician Phone

Primary Medical Insurance Company

Policy Holder

Policy #

Group #

List any allergies including bee stings, hives, asthma
Circle if applicable:
I use epi pen
I use inhaler

If Yes, indicate Type:
My child can use this independently
Will the participant be taking any medications while attending the training/camp?

If yes, what?
Are there special considerations with regard to this medication?
Does the participant have any current or recent health problems? (Example: diabetes, epilepsy, recent surgery, injury, etc.)

If yes, please describe (include dates of occurrence)

Program Description:

Session #:

Fee:

Session Dates:

Session Location:
First Player's Signature*
Player's Address
Address Line 1:*
Street address, P.O. box, company name, c/o
Address Line 2:
Apartment, suite, unit, building, floor, etc.
Country:*
City:*
State/Province:*
Zip/Postal:*
Parent or Guardian's Email Address

Email*

Confirm Email*
Check to receive information, news, and discounts by e-mail.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Insurance

Insurance Carrier*

Insurance Policy Number*
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information

Father's Name:

Phone:

Mother's Name:

Phone:

In an emergency when parents cannot be reached, please contact:


Name:

Home Phone:

Work Phone:

Medical Information


Allergies

Other medical conditions

Player's Physician Phone

Primary Medical Insurance Company

Policy Holder

Policy #

Group #

List any allergies including bee stings, hives, asthma
Circle if applicable:
I use epi pen
I use inhaler

If Yes, indicate Type:
My child can use this independently
Will the participant be taking any medications while attending the training/camp?

If yes, what?
Are there special considerations with regard to this medication?
Does the participant have any current or recent health problems? (Example: diabetes, epilepsy, recent surgery, injury, etc.)

If yes, please describe (include dates of occurrence)

Program Description:

Session #:

Fee:

Session Dates:

Session Location:
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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