Emergency Information and Release Form
This form must be signed and returned no later than July 1, 2008
Campers Name:___________________________________Home Phone: ( )_______
Home Address:________________________________________Zip Code____________
Parent/Legal Guardian contact for emergencies:_________________________________
Home Phone:( )____________Work: ( )_____________Cell:( )___________
Alternate Contact:________________________Phone:___________________________
Relationship to camper:____________________________________________________
I consent to have the administrators and sports medicine staff of the Huskies Elite Soccer Academy act in our behalf in case of any emergency and hereby grant permission to said administrators/staff to authorize medical attention by a physician, nurse or hospital. I understand that any medical treatment is not payable by the Academy or administrators/staff.
Your Application is not complete without the following information. No camper will be permitted to participate in any capacity without all information filled out.
Health Insurance Information: Health Insurance is required of all participants. (No camper will be accepted into the Academy without medical insurance.)
Insurance Company:______________________________________________
Policy #:_________________________________________________________
Subscriber:_________________________Relationship to policy holder:_______
Release and Indemnification Agreement: I represent and agree that the camper will have sufficient health, accident, disability and hospitalization insurance coverage to cover any medical costs during participation in the Academy and understand that Northeastern University has no obligation to provide any such insurance or costs. In consideration that my child will attend the Elite Academy, I hereby release and discharge Northeastern University, its officers, employees, Trustees, Overseers, and agents form any claim arising out of participation in the Academy for personal injury, loss or damage to property or loss of life and further agree to indemnify, defend, and hold harmless the University and its officers, employees, Trustees, Overseers, and agents for any such claims.
Printed Name of Camper____________________________________________
Signature of Parent/Guardian:______________________________Date______