Medical Information

Name:

Address:

Medical Insurance Company Name & Policy No:

Daytime Phone Numbers:

In an emergency, if parents cannot be reached please notify:

I, the undersigned parent or guardian, do hereby authorize the athletic trainer or coaches at the Lawrence Fine Keeper camp to secure any and all medical treatment in the event that I cannot be contacted. I further authorize any attending physician to render any and all medical care which he or she may deem necessary.

It is understood that, in any event, an attempt will be made to contact the parent before treatment is started.

I, the undersigned for myself, my heirs, & executors waive, release and forever discharge Lawrence Fine, FineSoccer, Kick It LLC, Web Breez and all their affiliated entities from any and all liability, claims, demands, and causes of action for personal injury, property damage and/or other loss suffered by my child in connection with his participation in the Camp.

I, the undersigned parent or guardian, also certify that my child is physically fit to attend the Lawrence Fine Keeper Camp and participate in all camp activities.

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Parent or Guardian Signature              Date