e-soccercamps.com at Florida Atlantic University

Participant's Name
Age Grade Birth Year Gender
Address
City/State Zip
Parent/Guardian's Name
E-mail Address
Home Phone Work Phone Cell Phone
Emergency Contact Emergency Contact Phone
Preferred Position

Please make checks payable to:
e-soccer.com, inc.
Send application, medical release form and payment to:
e-soccer.com, inc.
P.O. Box 810971
Boca Raton, FL 33481-0971

Medical Release/Hold Harmless Agreement

I approve of my child attending the e-soccer.com camp at Florida Atlantic University, and I certify that she is in good health and able to participate in all the activities. I authorize the staff of e-soccercamps.com to act for me according to their judgement in an emergency requiring medical attention, including treatment by physicians.

By signing below, I hereby assume any and all risks which are incumbent with any excursion of program and extracurricular activities in which my child might participate, with realization that these activities may subject her to personal bodily injury or property damage risks. I am aware that certain dangers may occur including, but not limited to, physical contact with other individuals and/or athletic equipment and facilities which may result in cuts, abrasions, sprains, strains, bruises, concussion and fractures. Being fully aware of these dangers, I nevertheless, voluntarily choose to allow my child to participate in the e-soccercamps.com program and assume all the risks arising therefor.

I so hereby release, acquit, and forever discharge the State of Florida, Florida Atlantic University and all who plan, direct or otherwise participate in the aforementioned program, and from all actions, account of any and all injury, directly or indirectly sustained by my child as a consequence of her participation in the above mentioned sports camp. I will be responsible for any medical or other charges in connection with attendance at camp. I have read and understand the foregoing assumptions of this risk and release document, and I do freely accept its terms.

Parent/Guardian Name __________________________________
Signature and Date _____________________________________
Insurance Company Name ________________________________
Policy # __________________________________________