Gender:
Parent's
Name:
Child's Name:
Home Address
(street):
City:
School:
Home Phone:
E-mail Address:
List Allergies:
List Medications:
Emergency Contact Number 1:
Emergency Contact Number 2:
Submission
of this registration for the IPFW Mini Dons Soccer clinic agrees
to the following. I hearby authorize any medical evaluation or treatment
which may be advised or recommended by the attending medial personnel
of the IPFW Mini Dons Soccer Camp. Waiver and release are required
for all participants. In consideration of my application being accepted,
intending to be legally bound do, hereby, for myself, my heirs, executors
and administrators, waive, release and forever discharge any and
all claims for damages, which I may or participant may hereafter
occur, against IPFW or its, or their respective officers, agents,
representative, successors, and/or assignees, for any or all damages
which may be sustained or suffered by me in connection with my association
with or participation in on the grounds of Hefner Soccer Fields.
I, the parent or guardian, do hereby agree to the above waiver and
relase.
Parent/Guardian
Signature:
Date:
Comments:
Please list any comments that may be of assistance to the Staff of
the IPFW Mini Dons Soccer Camp.
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