Pacific Coast Soccer Camps Registration Information Phone: 425-327-8840 www.pacificcoastsoccercamps.com email: bobbymcl@comcast.net 10402 51st Pl W, Mukilteo, WA 98275 Name_________________________________________ Birthdate______/______/______ Address_________________________________________ City_____________________ Zip_____________ Home phone________________________ Business phone_________________________ Email______________________________ Emergency name________________________________ Emergency phone_____________________________ Session registering for___________ Medications/conditions___________________________________________________ Pacific Coast Soccer Camps, Inc Waiver and Consent to Medical Care and Treatment I understand that participation in any sport, including soccer, may entail serious risks including but not limited to, serious neck and spinal injuries resulting in complete or partial paralysis, brain damage, injury to virtually all bones, joints, muscles, internal organs, even death. I am voluntarily participating in this activity with full knowledge of the risks and hereby accept and consent to said risks. I further understand that medical assistance is not available at the soccer camp and nonetheless I agree to proceed with the activities of the soccer camp. Pacific Coast Soccer Camps does not provide any accident or health coverage for its participants, and it is the responsibility of the participant or legal guardian to provide that coverage while participating in the soccer camp. I hereby consent to and authorize all staff members to give me any emergency medical treatment which may be necessary because of any injury I may sustain while participating in the soccer camp. I also authorize and consent to being transported by ambulance, aid car, airlift, or private vehicle to an emergency medical center for treatment of any injury I may sustain while participating in the soccer camp. I further consent to such medical, dental, surgical, and hospital care and treatment by a licensed physician, dentist, hospital, and hospital staff as is deemed immediately necessary and/or advisable in order to safeguard my health. I assume all responsibility for, and all risk of injury and/or death which may occur to me while participating in the soccer camp. I hereby release and discharge Pacific Coast Soccer Camps, Inc., its shareholders, officers, directors, instructors, agents, and lessee from any and all present and future claims, demands, rights or causes of action, whether known or unknown, anticipated or unanticipated, and resulting from or arising out of, or incident to, the undersigned's participating in the soccer camp. I further release any and all persons, professional or otherwise, from any claims whatsoever on account of first aid, medical, hospital, dental, and/or other treatment or service rendered me, including but not limited to transportation for purposes of receiving such treatment, for any injuries I may sustain while participating in the soccer camp. I have carefully read the foregoing consent and release and know the contents thereof and sign this consent and release as my free and voluntary act. All photos taken at camp may be used for promotion and advertising.
Player's name(print)____________________________ Parent name(print)________________________ Parent/Guardian signature:__________________________________________________Date_________ Medical Insurance Carrier_______________________________ Policy #_____________________ Physician's name ______________________________ Phone___________________________ Where did you hear about us?__________________________ PAYMENT INFORMATION Day Camps: payment in full with registration. Confirmations via e-mail.