| Name of Insurance Company: | | |
| Policy Number: | | |
| Special Medical Instructions (i.e. allergic reactions, current medications, chronic illlness or injury, etc): | | |
| Name of Physician: | | |
| Phone Number: | | |
| Medical Release & Consent Form |
| I certify that my child is medically qualified to attend the Blue Ridge Soccer Academy. I understand that participation in any sport may cause physical injury and do hereby agree to release, discharge, and hold harmless the Blue Ridge Soccer Academy, Blue Ridge Soccer & Sports, Sweet Briar College, its staff and the facilities from all causes, liabilities, damages, claims, or demands whatsoever on account of any injury or accident involving my child while at camp. |
| I hereby authorize the staff of Blue Ridge Soccer Academy to act for me according to their best judgement in any emergency requiring medical attention. I give permission for an athletic trainer, physician and/or hospital emergency room staff to administer necessary care. I hereby give the Blude Ridge Soccer Academy permission to use my child''s name and/or picture in promotional camp literature and advertisements, and fully renounce all claims of reimbursement for use of this material. |
| Required: | | * |
| Name of Camper: | | * |
| Name of Father: | | * |
| Phone (H): | | * |
| Phone (W): | | * |
| Name of Mother: | | * |
| Phone (H): | | * |
| Phone (W): | | * |
| Email: | | * |
| Other Phone(s): | | |
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