Hoover Boys Soccer Permission Form

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PERMISSION AND MEDICAL RELEASE FORM:
The following form must be filled out by a parent or guardian of every athlete attending Hoover Boys Soccer Team Camp at Hargis Christian Camp.

For any questions or concerns, please reach out to Dani Proctor (FCA Staff) at dproctor@fca.org.

Item Link List Item 1

ATHLETE'S FIRST NAME:

ATHLETE'S LAST NAME:

PARENT/GUARDIAN FIRST NAME:

PARENT/GUARDIAN LAST NAME:

PARENT/GUARDIAN PHONE:

PARENT/GUARDIAN EMAIL:

ALTERNATE EMERGENCY CONTACT - FIRST AND LAST NAME:

ALTERNATE EMERGENCY CONTACT - PHONE NUMBER:

Does registrant have any known physical disability or illness which might interfere with their participation in strenuous activity?

Yes

If you indicated "yes", please explain physical defect or illness.

Does registrant have any severe allergies or reactions to drugs or medicines?

Yes

If you indicated "yes", please explain the allergies or reactions.

Does registrant have any severe allergies or reactions to food?

Yes

If you indicated "yes", please explain the allergies or reactions to food.

Is registrant presently taking any medications or on any special diet or exercise restrictions? Please include all over-the-counter medications such as Tylenol, etc.

Yes

If you indicated "yes", please list specific details (name of drugs, dosage, etc.)

Does registrant have any emotional/social disabilities that would be helpful for us to be aware of?

Yes

If you indicated "yes", please explain the emotional/social disabilities.

Does the registrant have any history of concussions?

Yes

If you indicated "yes", please explain the history of concussions.

Date of last Tetanus shot:

Is registrant living with:

Health Insurance - Insurance Company:

Health Insurance - Policy Number:

Health Insurance - Medial Doctor, First and Last Name:

Health Insurance - Medical Doctor Phone Number:

FCA Student Permission Waiver: I recognize that there may be occasions where the student named above may be in need of first aid or emergency medical treatment as a result of an accident, illness, or other health condition or injury. I do hereby give permission for agents of this organization to seek and secure any needed medical attention or treatment for the student named above including hospitalization, if in the agent’s opinion that such need arises. In doing so, I agree to pay all fees and costs arising from this action to obtain medical treatment. I give permission for camp trainer and camp professional medical staff to give over-the-counter medications as needed, as well as, attending physician(s) and other medical personnel to administer any needed medical treatment, including surgery, and again, I agree to pay for the medical treatment. I give permission for my student to be transported to a medical center in an emergency situation.

I have read and agreed to the terms above.

Release to Use Image and Likeness: On occasion, the Fellowship of Christian Athletes (FCA) or its representatives takes photographs or makes an audio or videotape recording of children and/or adults involved in activities. Such photographs, video records of social media posts , may be used by staff and participants to remember the activities and participants. Local newsorganizations may hear of our activities or events, and our organization may invite or allow them to photograph or record our events for news reporting on special interest features. I consent to the use of any such audio or visual record of the student named above to be used, distributed, or displayed as agents of the organization see fit. This consent includes but is not limited to photographs, videotape, and audio recordings. Furthermore, I give permission for the student to be interviewed by the news media, or for such photographs and other audio visual records to be used by the news media. In addition, such photographs and audio/visual recordings may be used in publications or advertising materials to let others know about our activities. These images may also be used by FCA or its agents to produce ministry resources for staff training, Camp or Campus Ministries, or other uses to promote the ministry of FCA. FCA may also make these materials available for sale to the public.

I have read and agreed to the terms above.

I further agree to indemnify and hold harmless FCA and its leaders, employees, volunteers, or agents from any and all claims arising from my student’s participation in its activities and programs, or as a result of injury or illness of my student during such activities. I represent that I am the parent/guardian of the attendee who is under 18 years of age. I have read the above Student Permission Waiver Form and am fully familiar with the contents thereof. I give permission for the student named above to participate in the activities of this organization, including any special events/activities described above. In consideration for allowing the participation of the student in these activities, I hereby consent to the Student Permission Waiver Form, including the Release of Liability above, on behalf of the student and agree that this Student Permission Waiver Form shall be binding upon me, my family, heirs, legal representatives, successors, and assigns.

I have read and agreed to the terms above.

By checking the box below, you are submitting that you are representing the parent/guardian of the attendee who is under 18 years of age and agreeing to the following statements: I have read the above Student Permission Waiver Form and am fully familiar with the contents thereof. I give permission for the student named above to participate in the activities of this organization, including any special events/activities described above. In consideration for allowing the participation of the student in these activities, I hereby consent to the Student Permission Waiver Form, including the Release of Liability above, on behalf of the student and agree that this Student Permission Waiver Form shall be binding upon me, my family, heirs, legal representatives, successors, and assigns.

I have read and agree to all the terms above.

First and Last Name of Signee:

Birthdate of Signee:

Thank you for filling out our waiver for the upcoming Team Camp!

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Contact Info

Mailing Address:

GBFCA

5184 Caldwell Mill Rd, Suite 204-286

Hoover, AL 35244

Bill Gray, Multi-Area Director

bgray@fca.org

205.612.1636

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