Camper consent form W/L — Let the Kids Play Soccer Camp

LTKP CAMPer CONSENT FORM

Parent/Guardian name

First Name

Last Name

Parent/Guardian email

Parent/Guardian phone number

(###)

###

####

Home address

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

Camper's information

Child's name

First Name

Last Name

Child's birthday

YYYY

Child's T-shirt size

T-shirt are in kid sizes

I consent for my child's image to be used in promotion photographs/video

Camper behavioral rules and expectations

1. Treat other campers with respect and kindness. 2. Always keep your hands to yourself. 3. Respect one other’s personal space. 4. Name-calling is unacceptable — no inappropriate language. Bullying will not be tolerated. 5. Listen and be respectful toCamp staff members at all times. 7. Food and drink belong in designated areas only. Campers must clean up after themselves whenever having food or drink. All garbage and recycling must be put in its proper receptacle, and absolutely no throwing food and eating items on the ground. 8. Take good care of the facilities and equipment. 9. Ask for permission to go anywhere – always take a “buddy” with you. 10. Phones and other devices cannot be used during soccer instruction.

I've read, understood & consent to the camp behavioral rules and expectations above

Medical Information

Notify us immediately if the Camper develops any illness prior to or on the day of the camp. If your child is found to have any of the symptoms listed below while participating in the program, we will isolate them from the other children and call you to pick them up immediately: - Severe coughing - Difficult or rapid breathing - A fever of 100 F or above - Unusual spots or rashes - Vomiting - Yellow eyes or skin - Tears, redness of eyelids w/ discharge - Infected skin patches - Sore throat or trouble swallowing - Severe itching of body or scalp - Headache or stiffness of neck - Mouth sores with or without drooling - Nasal discharge - Loss of taste or smell

Does your child have special instructions for medical treatment? If yes, please explain including the medication your child is taking. If medication must be taken during camp hours, please fill out a Physician Request for Administration of Medicine Form. .

The information you provide will be held in confidence

Does your child have or had Asthma, Kidney Disease, Diabetes, Heart Murmur, Seizures, Hay Fever or other?

Please explain in detail

Does your child have special dietary requirements? If so, please specify. Describe any diagnosable food allergies.

Include the level of severity and preferred plan of action.

Does your child have medical insurance?

Medical Insurance Provider Name

Describe any diagnosable behavioral needs of your camper. Include the preferred plan of action.

The information you provide will be held in confidence

Name of Physician

First Name

Last Name

Physician's phone number

(###)

###

####

I've read, understood & consent to the medical information above

Emergency Contact and Pick-up/Drop off Approval

Emergency contact #1

First Name

Last Name

Emergency contact #1 phone number

(###)

###

####

Does Emergency Contact #1 have your permission to drop off and pick up your child?

Emergency contact #2

First Name

Last Name

Emergency contact #2 phone number

(###)

###

####

Does Emergency contact #2 have your permission to drop off and pick up your child?n

Consent and Authorization

I, the undersigned, hereby declare and affirm that:

I am the parent/legal guardian of the youth named above (hereinafter referred to as "Child"), who is under my care and responsibility. I hereby consent and give authority to the participation of my Child in the scheduled youth activities of the Camp, and all other activities which is supervised and customarily associated with its youth group. I hereby declare and affirm that my Child is physically fit to take part in the Camp's activities and my Child has no known illness or adverse medical condition that would render him/her unfit to participate therein, other than the information specified in the medical information above. I shall immediately advise the organizers in writing, should I discover any illness, adverse medical condition, or any other physical defect that would render my Child unfit to participate in the recreational and sporting activities of the Camp. I shall notify the organizers immediately in case I revoke my consent to the Camp for this event.

Authorization for Medical Treatment

I understand that in case of medical emergencies involving my Child, I shall be notified right away. In case any of my provided contact information is unreachable, I authorize the organization to call the doctor indicated above. In case that the doctor is not available, I authorize the organizers to call any doctor to provide the necessary medical attention to my child. I understand that the camp shall not be responsible, and shall be reimbursed, for any medical expenses incurred by them over this authorization.

Knowing this and by submitting my selection of the “I agree to this Parental/Guardian Consent Agreement Form”, I am agreeing to release, indemnify and hold Let The Kids Play soccer camp and Staff harmless forever from any and all liability costs, including attorney fees, associated with or arising from the participation of the Camper listed in this form in Let The Kids Play soccer camp. I am the parent or legal guardian of the Camper listed in this form. I have read, understood, and agree to the terms and conditions of this form, and understand that I am giving up substantial rights including my right to sue. I understand that I must notify Let The Kids Play soccer camp immediately if I revoke my consent to the terms and conditions on this form, that the withdrawal of my consent may result in the Camper’s inability to participate in Let The Kids Play soccer camp. I acknowledge I am accepting this Agreement freely and voluntarily, and intend by my acceptance a complete and unconditional release of all liability to the greatest extent allowed by law.

Digital signature of Parent/Guardian