CHOCTAW-NICOMA PARK SOCCER CLUB CAMP REGISTRATION FORM
NAME:_____________________________________ DOB:_______________
ADDRESS:___________________________________________________________
CITY:_______________________ ZIP:_________________
PARENT’S NAME:______________________________________________________
HOME #:________________________ CELL #:____________________________
EMAIL ADDRESS:_____________________________________________________
FIELD PLAYER: ________ GOALKEEPER:__________
SHIRT SIZE: YOUTH: YS___ YM___ YL___ ADULT: AS___ AM___ AL___ OTHER:_________
*********MAKE CHECKS PAYABLE TO: CNP SOCCER CLUB********
FEES: $35
PARENTAL PERMISSION, MEDICAL AUTHORIZATION, AND RELEASE
This Form must be completed and signed by a parent or guardian for any camp participant under age 18, or by the participant, if age 18 or over, before participating in any camp activities. Name of Participant: ____________________________________
I, ___________________________________________________________________, am the (circle one): Natural Parent Guardian Participant Other: (Explain) _____________
I hereby authorize the physicians/providers and staff of any medical facility to provide the above-named Participant with any and all medical treatments including examinations, x-rays, tests, anesthesia, operations and diagnostic procedures , which may be deemed necessary or advisable by the attending physician and/or surgeon. I also agree that the patient, when admitted, is to remain in the hospital until the attending physician/surgeon recommends the patient’s discharge. I have completed the attached Medical Information Form and have disclosed therein all information known to me about the Participant’s medical condition.
I further hereby give my approval to Participant’s participation in any and all CNP Soccer Camp activities. I acknowledge that the Participant will participate in athletic activities that could lead to serious injury. I grant permission for the Participant to participate in the soccer camp and I have no knowledge of any reason that Participant is not fully physically able to participate in all camp activities.
IN CONSIDERATION OF PARTICIPANT BEING ALLOWED TO PARTICIPATE IN THE CNP SOCCER CAMP, I EXPRESSLY AGREE THAT NEITHER CNP SOCCER CAMP, NOR ITS AGENTS, OFFICERS, EMPLOYEES/VOLUNTEERS (HEREAFTER REFERRED TO AS “CNPSC”) SHALL BE LIABLE FOR ANY DAMAGES ARISING FROM PERSONAL INJURIES SUSTAINED WHILE PARTICIPATING IN ANY CAMP ACTIVITIES OR AS A RESULT OF ANY CAMP ACTIVITIES, WHILE USING ANY CAMP FACILITIES OR WHILE PRESENT ON THE CAMP PREMISES. I ASSUME FULL RESPONSIBILITY FOR ANY SUCH INJURIES OR DAMAGES WHICH MAY OCCUR TO THE PARTICIPANT IN, ON OR ABOUT THE CAMP PREMISES OR WHILE USING CAMP FACILITIES OR WHILE PARTICIPATING IN OR AS A RESULT OF THE PARTICIPATION IN CAMP ACTIVITIES AND FURTHER AGREE THAT CNPSC SHALL NOT BE LIABLE FOR ANY LOSS OR THEFT OF PERSONAL PROPERTY. I ALSO SPECIFICALLY AGREE THAT CNPSC SHALL NOT BE RESPONSIBLE FOR SUCH INJURIES, DAMAGES, LOSS OR THEFT EVEN IN THE EVENT OF NEGLIGENCE BY CNPSC, WHETHER SUCH NEGLIGENCE IS PRESENT AT THE TIME OF THE SIGNING OF THIS DOCUMENT OR TAKES PLACE IN THE FUTURE.
Signature of Participant or Parent/Guardian: __________________________________
DATE: __________________________
ADDRESS:___________________________________________________________
CITY:_______________________ ZIP:_________________
PARENT’S NAME:______________________________________________________
HOME #:________________________ CELL #:____________________________
EMAIL ADDRESS:_____________________________________________________
FIELD PLAYER: ________ GOALKEEPER:__________
SHIRT SIZE: YOUTH: YS___ YM___ YL___ ADULT: AS___ AM___ AL___ OTHER:_________
*********MAKE CHECKS PAYABLE TO: CNP SOCCER CLUB********
FEES: $35
PARENTAL PERMISSION, MEDICAL AUTHORIZATION, AND RELEASE
This Form must be completed and signed by a parent or guardian for any camp participant under age 18, or by the participant, if age 18 or over, before participating in any camp activities. Name of Participant: ____________________________________
I, ___________________________________________________________________, am the (circle one): Natural Parent Guardian Participant Other: (Explain) _____________
I hereby authorize the physicians/providers and staff of any medical facility to provide the above-named Participant with any and all medical treatments including examinations, x-rays, tests, anesthesia, operations and diagnostic procedures , which may be deemed necessary or advisable by the attending physician and/or surgeon. I also agree that the patient, when admitted, is to remain in the hospital until the attending physician/surgeon recommends the patient’s discharge. I have completed the attached Medical Information Form and have disclosed therein all information known to me about the Participant’s medical condition.
I further hereby give my approval to Participant’s participation in any and all CNP Soccer Camp activities. I acknowledge that the Participant will participate in athletic activities that could lead to serious injury. I grant permission for the Participant to participate in the soccer camp and I have no knowledge of any reason that Participant is not fully physically able to participate in all camp activities.
IN CONSIDERATION OF PARTICIPANT BEING ALLOWED TO PARTICIPATE IN THE CNP SOCCER CAMP, I EXPRESSLY AGREE THAT NEITHER CNP SOCCER CAMP, NOR ITS AGENTS, OFFICERS, EMPLOYEES/VOLUNTEERS (HEREAFTER REFERRED TO AS “CNPSC”) SHALL BE LIABLE FOR ANY DAMAGES ARISING FROM PERSONAL INJURIES SUSTAINED WHILE PARTICIPATING IN ANY CAMP ACTIVITIES OR AS A RESULT OF ANY CAMP ACTIVITIES, WHILE USING ANY CAMP FACILITIES OR WHILE PRESENT ON THE CAMP PREMISES. I ASSUME FULL RESPONSIBILITY FOR ANY SUCH INJURIES OR DAMAGES WHICH MAY OCCUR TO THE PARTICIPANT IN, ON OR ABOUT THE CAMP PREMISES OR WHILE USING CAMP FACILITIES OR WHILE PARTICIPATING IN OR AS A RESULT OF THE PARTICIPATION IN CAMP ACTIVITIES AND FURTHER AGREE THAT CNPSC SHALL NOT BE LIABLE FOR ANY LOSS OR THEFT OF PERSONAL PROPERTY. I ALSO SPECIFICALLY AGREE THAT CNPSC SHALL NOT BE RESPONSIBLE FOR SUCH INJURIES, DAMAGES, LOSS OR THEFT EVEN IN THE EVENT OF NEGLIGENCE BY CNPSC, WHETHER SUCH NEGLIGENCE IS PRESENT AT THE TIME OF THE SIGNING OF THIS DOCUMENT OR TAKES PLACE IN THE FUTURE.
Signature of Participant or Parent/Guardian: __________________________________
DATE: __________________________