Apr 05

Medical Liability Waiver Form

To download free Liability waiver form in PDF, please click Medical Liability Waiver



Allergies to Medication:
Allergies to Foods:
Last Tetanus Immunization (Date)
Chronic or Recurring Illnesses
Operations/Injuries (include date)
Physical Restrictions
Physican Phone Number
Dentist Phone Number
Medical Insurance Provider
Policy Number
Parent/Guardian Signature
Date
Asthema
Camper Name
MEDICAL RELEASE & LIABILITY WAIVER
The Tony Amato Soccer Camp is not responsible for medical conditions not disclosed. A First Aid Responder will be available at camp throughout the week. Please check all that apply:
Bleeding Disorders
Convulsions
Heart Disease
Head Injury
Concussions
Seizures
Diabetes
I, ______________________________, agree to conform to the regulations of the Tony Amato Soccer Camps at the University of Arizona (UA) as the parent and/or legal guardian of the above named camper. I understand that all rules and regulations for the camp will be enforced and any violation by my child will result in a phone call to me with a possible request to come and pick up my child with no refunds being given. I do hereby waive, release, discharge the Tony Amato Soccer Camp, The University of Arizona, and respective staffs & employees from any and all rights and claims for damages resulting from injuries to my person or property that may be sustained or suffered by my in connection with my association with, participation in, or arising out of traveling to or from the Tony Amato Soccer Camp. We, the parents or guardians, agree to the above’s participation in this program including emergency and referral services, if necessary. I have read and hereby accept the conditions described. The Tony Amato Soccer Camp is not an official function of The University of Arizona.
I HEREBY AUTHORIZE IN ADVANCE ANY NECESSARY MEDICAL TREATMENT REQUIRED BY THE ABOVE NAMED CHILD WHILE IN ATTENDANCE OF THIS CAMP. I ALSO ACKNOWLEDGE THAT I HAVE/WILL NOTIFY THE CAMP PERSONNEL OF ANY SPECIAL MEDICAL NEEDS OR INFORMATION REQUIRED BY THE ABOVE NAMED CHILD

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