To be completed for the player by a parent or guardian Player's Full Name(Required) First Last DOB(Required) MM slash DD slash YYYY Male/Female(Required) Male Female Medical HistoryHas your child sustained a concussion in the last 8-weeks? Yes No If yes, please complete the following questions: Did they see a registered Doctor / professional(Required) Yes No Did they require a CT Scan(Required) Yes No Have they been given the 'green light' to participaite in sports(Required) Yes No Does your child suffer from any medical condition, which may affect his/her performance while in attendance at one. Soccer? (Please note failure to answer this question could affect the overall experience for the player, but more importantly place them in undue harm)(Required) Yes No If yes, please explain below:(Required)Is your Child currently taking any medication? If yes please list all medications. Type "NO" if your child is not taking any medications(Required)Does your Child suffer from any allergic reactions or minor allergies? If yes please explain below. If not, type "NO"(Required)Is your child Asthmatic?(Required) Yes No RELEASE OF LIABILITY 2022Student's Name First Last Age(Required)Sex(Required) Male Female Date of Birth(Required) MM slash DD slash YYYY I have enrolled the above-named child (“Child”) in the one. Soccer Schools program (“Program”). I understand the Child’s participation in the Program involves exposure to the inherent risks of soccer that cannot be eliminated. I also understand that the Child’s participation in the Program may involve a potential risk of injury. The risks include, but are not limited to, those caused by the playing surface, the equipment used, and the actions of other people including, but not limited to, other participants in the Program. Individually and as the parent or guardian of the Child, I HEREBY EXPRESSLY ASSUME ALL RISKS associated with the Child’s participation in the Program including all risks associated with soccer or using equipment intended to improve or enhance the Child’s soccer skills. Date of Birth Despite my understanding of the foregoing risks, I, individually and as the parent or legal guardian of the Child, AGREE TO NOT SUE AND TO RELEASE FROM LIABILITY AND TO DEFEND, INDEMNIFY AND HOLD HARMLESS one. Soccer Schools (one. Skill Factory, Inc.), its Board of Directors and representatives, employees and agents for any damage or injury arising out of the Child’s participation in the Program regardless of cause, including NEGLIGENCE. I understand that the foregoing is a LIABILITY RELEASE that is legally binding on me, the Child, our heirs and our legal representative and I sign it of my own free will. I furthermore acknowledge that the foregoing is binding during the 2022 Spring/ Summer/Fall/Winter soccer camp season. Also, I hereby give my consent for emergency medical care prescribed by a duly licensed Doctor of Medicine. This care may be given under whatever conditions are necessary to preserve life, limb and/or well-being of my Child.Signature of Parent or Guardian(Required) Reset signature Signature locked. Reset to sign again Date(Required) MM slash DD slash YYYY Print Name of Parent/Guardian(Required) First Last Insurance Carrier(Required) Policy Number(Required) EMERGENCY CONTACTName(Required) First Last Relation(Required) Primary Phone(Required)Alternate Phone
