Parental Consent Form

Word Document

Camper Name
_______________________________________________________________________
Age
_______________________________________________________________________
Date of Birth
_______________________________________________________________________

Does the camper have any:
Allergic Reactions
_______________________________________________________________________
Present Medications
_______________________________________________________________________
Other conditions that the Camp Administration should know about:
_______________________________________________________________________

_______________________________________________________________________

_______________________________________________________________________

Emergency Contacts

Primary Contact:
Name _________________________________________________________________

Home Phone ___________________ Alternate Phone  _________________

Secondary Contact:
Name _________________________________________________________________

Home Phone ___________________ Alternate Phone _________________

Insurance company:
_______________________________________________________________________

Policy holder:
_______________________________________________________________________

Policy number:
_______________________________________________________________________

PARENTAL STATEMENT:

I hereby verify that my child is physically fit to play the contact sport of Soccer. In addition, I authorize any emergency treatment deemed necessary for my child to be administered by the provided training staff and agree not to hold the training staff, Hampden-Sydney College, the coaches, or the Soccer camp staff liable for any injuries.

Parental permission must be obtained before medical treatment can be rendered to a person under 18 years of age. This consent form should be read and signed by a parent or guardian so that indicated care might be given with no unnecessary delay. No major procedures will be performed except in extreme emergency, without parents being notified and fully informed. In the event that a parent does not want treatment rendered under any circumstance, they should cross out the word "give" on the form below and insert the word "refuse". If the form is not signed, it will be interpreted as a refusal of permission. Please note that your child may not participate in the Soccer camp until we receive the signed Parent Consent form.

I GIVE PERMISSION TO THE COLLEGE HEALTH CENTER & CAMP TRAINING STAFF TO CARRY OUT SUCH EMERGENCY DIAGNOSTIC AND THERAPEUTIC PROCEDURES AS MAY BE NECESSARY FOR MY CHILD AND IN THE PHYSICIANS' ABSENCE, FOR THE TRAINING STAFF ON DUTY TO RENDER EMERGENCY CARE IN LINE WITH STANDING ORDERS, AND ALSO PERMIT SUCH PROCEDURES TO BE CARRIED OUT AT AND BY ONE OF THE LOCAL HOSPITALS IN THE EVENT THAT MY CHILD HAS BEEN SENT OR TAKEN THERE FOR EMERGENCY CARE. I ALSO ACKNOWLEDGE THAT, IN THE EVENT OF AN INJURY, THE CAMP INSURANCE WILL ONLY BE USED AS SECONDARY COVERAGE.

I declare that I am the father / mother / guardian (circle one) of the above-named minor/camper.

Signature
_____________________________________________________________________

Date
_____________________________________________________________________

This form must be completed prior to registration, to allow camp participation.
Mail to: Elite Soccer Camps, Hampden-Sydney College, Box 698, Hampden-Sydney, VA  23943.

Last modified: 1/14/2011