Butler Soccer Camp Forms

BU Soccer Camp

Please fill out and sign this Medical/Insurance Form and Media Release at least week prior to the start of your camp.

Your camper cannot participate in camp unless the form has been received.

Soccer Camp Attendee:*
First Last
PHOTO / MEDIA RELEASE*
I grant to BU Soccer Camp the right to use, reproduce, assign, and/or distribute photographs, films, videotapes, and sound recordings of my camper for use in materials they may create for camp promotional use.
MEDICAL / INSURANCE RELEASE*
AUTHORIZATION: I consider the above named camper to be in good health, and permission is granted to participate in all camp activities, unless otherwise indicated on this record. In case of illness and or injury, permission is granted for medical treatment to be rendered to my child.
WAIVER AND RELEASE:*
I do hereby waive, release and discharge BU Soccer Camp and respective staff and employees from any and all rights and claims for damages resulting from injuries to my child’s person or property which may be sustained or suffered by in connection with his/her association with or participation in, or arising out of my traveling to or from BU Soccer Camp. We, the parents or guardians, agree to the above waiver and release:
Parent or Guardian Signature*
by inputting your full name above you allow the attendee listed above to participate in 2021 soccer camp activities.
Insurance Company’s Names:*
Policy Holder’s Name:
First Last
Policy Number:*
List any allergies to medications:
List any pertinent medical info (diabetic, surgery, allergy…)
Family Doctor's Name:*
First Last
Family Doctor's Phone Number:*
Parent Cell Number 1:*
Parent Cell Number 2:
Emergency Contact:*
First Last
Emergency Contact Phone Number:*
Comments
This field is for validation purposes and should be left unchanged.