Coeur d’Alene – Border LeagueFootball Camp – June 16th– 20th
Information, Insurance and Liability Form
Cost $150 – Checks made out to CHS Football
*All Camp Moneyand Paperwork is due May 23rd – Turned in to Coach Amos
*Some Funds from this camp may to Coaching Needs/Clinics
Player Name: ______Grade (Fall 14): ______
Address: ______
StreetCityStateZip Code
Home Phone: ______Player Cell: ______
Player E-Mail: ______T-Shirt Size: ______
(Adult sizes)
Parent E-Mail: ______
Parent Names: ______
Contact #’s
Mothers Work: ______Cell Phone: ______
Fathers Work: ______Cell Phone: ______
Emergency Contact (other than parent)
Name: ______Relationship: ______
Home/Work Phone: ______Cell Phone: ______
Proof of Medical Insurance for Participant:
I do hereby, on my own behalf and on the behalf of the participant understand that I am required to maintain and carry accident medical insurance coverage for the participant for the duration of the football camp. By my signature below I am verifying and warranting that the participant does have such coverage
I certify that ______(camp participants name)
has medical insurance with ______(Medical Insurance Company)
under the policy # ______
And has dental insurance with ______(Dental Insurance Company)
under the policy # ______
This insurance effectively covers any medical or dental cost incurred as a result of participation in the Cd’A Border League Football Camp.
______Parent or Guardian Signature
______Current Medications & Allergies
Release of Liability:
In consideration of the participant involvement in the Cd’A Border League Football Camp, and on behalf of the participant, waive and release forever, any and all rights, claims, and/or damages the participant may have against the Cd’A Border League Football Camp, the Coeur d’Alene High School coaching staff, employees, agents, volunteers and any other school/staff participating in the camp.
Assumption of Risk:
I do hereby, and on behalf of the participant accept, understand and assume that participation in the football camp carries with it certain inherent risks that cannot be eliminated regardless of care taken to avoid injuries. I do hereby, and on behalf of the participant and understand and assume these risks include minor injuries and more serious injuries, including possible permanent physical and or mental damage and even paralysis or death. I do hereby, and on behalf of the participant, agree that the participant has agreed to follow all instructions of coaches and camp staff, and to wear all necessary, recommended, and appropriate protective gear and equipment during the course of the Cd’A Border League Camp.
Indemnity and Hold Harmless Agreement:
I do hereby, and on behalf of the participant agree to indemnify and hold coaches, camp staff, and all school/teams from any and all claims, actions, suites, procedures, costs, expenses, damages, liabilities, and any attorneys’ fees brought as a result of the participants involvement in the Cd’A Border League Camp, and I agree to reimburse the coaches, camp staff, and Cd’A High School and all schools participating in the camp any such expenses.
Consent for Medical Treatment and Authorization Release:
I do hereby, on my own behalf, and on the behalf of the participant give consent to the Cd’A coaching staff and camp medical staff, employee, agents, and volunteers to obtain medical or dental treatment and assistance on my participants behalf, if such treatment should be necessary or desirable during the course of the participation in the Cd’A Border League Camp. I do hereby, and on behalf of the participant acknowledge, however, that I will be solely responsible for the cost of such treatment, or for any other medical or dental treatment, for the participant. In the case of emergency and a parent or guardian cannot be reached, I do hereby, on my behalf and on the behalf of the participant authorize the coaching staff and or Cd’A school district personnel to obtain whatever medical or dental treatment the participant or medical or dental personnel deems necessary including emergency treatment, that includes but is not limited to, operative procedures, if necessary for the welfare of the participant. I do hereby, and on the behalf of the participant further understand that I will be financially responsible for all chargers and fees incurred in the rendering of such treatment, regardless of whether or not my medical insurance would cover such charges and fees.
I have read, understand and agree with the above information:
______Parent or Guardian Signature
______Printed Parent or Guardian Name
______Player Signature
______Printed Player Name