Player's Name:__________________________________ Guardian's Name:________________________________ Guardian's E-mail:______________________________ We understand that our child may become injured or ill during a Soccer Club activity even though he/she is physically fit. We give permission for North Seattle Soccer Camp representatives and coaches to take emergency action on behalf of our child and to obtain transportation to emergency facilities when we are not present or available. We also give our permission to have a Medical Doctor, Dentist, Nurse, Hospital or Clinic provide medical assistance and/or treatment. All expenses associated with this treatment will be paid by our medical insurance or by us. Player's Doctor:_______________________________ Phone:_____________________________ Preferred Hospital:________________________________________________________________ Player's allergies and/or medical conditions:______________________________________ Medications taken regularly:_______________________________________________________ Physical restrictions:_____________________________________________________________ Person to notify in case of emergency:_____________________________________________ Relation:________________________________ Phone:___________________________________ Second person to notify in case of emergency:______________________________________ Relation:________________________________ Phone:___________________________________ Insurance Company:___________________________ Policy Number:_______________________ It is also understood that photographs and/or video footage may be taken of my child for the purposes of training, promotion (paper or web-based), or reporting of camp activities. We give permission for North Seattle Soccer Camp representatives and coaches to use the images for these stated purposes. Signature of Parent/Guardian:___________________________________ Date:_____________ Address of Parent (if different from submitted form):______________________________ ___________________________________________________________________________________
THIS FORM MUST BE MAILED OR BROUGHT TO THE FIRST DAY OF CAMP IN ORDER FOR YOUR CHILD TO PARTICIPATE
Mail to: North Seattle Alliance Church
2150 N. 122nd St.
Seattle, WA 98133