The Soccer Institute - TSi Premier Soccer Club
17445 Huntley Road – Windsor, OH 44099
P.O. Box 340 Huntsburg, OH 44046 (440) 708 – 6053 Emergency mobile
Participation and Medical Release
2010 – 2011 LIABILITY RELEASE
As the Parent and/or legal guardian of ______, a participant (“Participant”) in The Soccer
(Print Child’s Name)
Institute, TSi Premier club, camp, clinic, training program, tournament or event referred to as (“program”); for and on behalf of the Participant, myself, participants other parent, our heirs, executors, and assigns, in consideration and as a requirement for the right of Participant to participate in the Program, hereby (i) assume all risks of injury, disease, or any malady which may arise from Participant’s participation in the program and (ii) release and discharge The Soccer Institute, Deer Valley Camp, AOA, employees, owners, contractors, vendors, professional and volunteer staff, and agents (individually and collectively referred to as “Released Parties”) from and against any and all liability or damages of every nature, kind and description whatsoever arising out of the “program” and/or Participant’s participation therein. We also consent to use of digital photographic images of participants on the website and promotional print materials with the understanding that all such images are the exclusive property of The Soccer Institute.
On behalf of Participant and parent/guardian, I (we) agree to indemnify and hold harmless the Released Parties of and from all claims, demands, actions or causes of action of any kind or nature, in law or in equity arising from or relating in any way to the “program” and/or Participant’s participation therein. This indemnification and hold harmless agreement, shall include, without limitation, any and all claims, demands, actions or causes of action arising from or relating in any way to injuries or damages (physical, health, psychic, economic, or otherwise) which anyone or anything may suffer or sustain by involvement in the “program” which may include, but is not limited to: sports, equestrian, aquatics – lake swimming, boating, fishing, natural events resulting from fallen tree limbs, insect or animal bites, communicable disease, food poisoning, reaction to specific foods, allergic reactions of any kind, exposure to sun, wind, and automobile injuries while at or in transition to or from program activities. This indemnification and hold harmless agreement specifically includes, but is not limited to, the payment of all litigation expenses and attorney’s fees which may be incurred by The Soccer Institute and “released parties” as needed to defend any actions.
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Signature of Parent/GuardianDateEmail:
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Print Name of Parent/GuardianMobile Phone:
PARENT AUTHORIZATION MEDICAL FORM
Parental permission or power of the guardian is required in hospitals for X-rays and treatment following diagnosis of all injuries requiring sutures, dressings, medications, and surgery.
I (we) give this authority to The Soccer Institute, TSi, Director or his representative.
I (we) certify that we have medical insurance and assume fiscal responsibility for any medical expenses.
I (we) give permission for medical treatment in case of emergency or injury requiring first aid and authorize transportation of our child by EMS or “Program” personnel to a medical facility for care.
I (we) also agree by signing that our child is in good health and able to participate in vigorous activity.
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Signature of Parent/GuardianDateSignature of Parent/GuardianDate
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CHILD / PARICIPANT’S NAMED. O. BMedical Insurance Company and Policy number
Emergency Contact: ______Phone 1: ______Phone 2: ______
Participant’s Home Address:______
Please list any allergies/medical conditions/restrictions, prescriptions and attach any instructions on back.