Emergency Medical Release & Liability Waiver

Participant's Name______________________________Birthdate__________________

Street Address_____________________________City___________Zip Code_______

                                                              Emergency Information

Father's Name______________Home Phone(___)________Cell Phone(___)_________

Mother's Name_____________Home Phone(___)________Cell Phone(___)_________

In an emergency when parents/guardians cannot be reached or is not applicable, please contact the following:

Name_____________________Home Phone(___)________Cell Phone(___)________
Name_____________________Home Phone(___)________Cell Phone(___)________

Allergies______________________________________________________________

Other Medical Conditions_________________________________________________
Physician__________________ Phone(___)_____________Bus Phone(___)_________ Medical/Hospital Insurance Company___________________Phone(___)____________
Policy Holder's Name__________________________Policy Number_______________

THIS AUTHORIZATION FOR EMERGENCY MEDICAL TREATMENT MUST BE COMPLETED BEFORE PARTICIPANT CAN PARTICIPATE IN ACTIVITIES. TREATMENT FOR INJURY WILL BE BASED ON INFORMATION PROVIDED HEREIN.

I the undersigned participant and parent/guardian of the above listed minor (if participant is under the age of 18) acknowledge and fully understand that Each participant will be engaging in activities that involve risk of serious injury, including permanent disability or death, and severe social and economic losses which might result not only from their own actions, inactions or negligence, but action, inaction or negligence of others, the rules of play, or the condition of the premises or of any equipment used and further, that there may be other unknown risks not reasonably foreseeable at this time, assume all the foregoing risk and accept personal responsibility for the damages following such injury, permanent disability or death, hereby release, discharge, covenants to indemnify and not to Before U Kick Incorporated, its directors, officers, employees, contractors, consultants, coaches, managers, agents, representatives, sponsors and associated personnel including those of its affiliated organizations, and the owners and lessors of premises used to conduct the event, all of which are hereinafter referred to as releasees, including Accotink Academy, City of Manassas Public Schools, Fairfax County Public Schools, Fairfax County Park Authority, Lehigh University, and the University of Virginia, from any and all liability to each of the undersigned, His/her heirs or next of kin for any and all against any claim by or on behalf of the applicant as a result of the applicant's participation in the Camp and/or being transported to or from the same, which participation, after careful consideration I hereby authorize, and which transportation I hereby authorize. The applicant/participant had received a physical examination by a physician and been found physically capable of participating in the Camps. I hereby give my consent to have an athletic trainer, coach and/or doctor or medicine or dentistry or associated personnel to provide the applicant/participant with medical assistance and/or treatment and agree to be financially responsible for the cost of such assistance and/or treatment. I, also agree to save and hold harmless and indemnify each and all parties herein referred above as releasees from all liability, loss, cost, claim or damage whatsoever, including death or damage to property, which may be imposed upon said releasees because of any defect in or lack of such capacity to so act or caused or alleged to be caused in whole or in part the negligence of the releasees. I have read the above waiver/release and understand that (I) we have given up substantial rights by signing this release and sign below voluntarily. I understand that this document may not be altered in any manner and that any alternation without the express written consent from Before U Kick Incorporated will cause the participant to be removed from the Camp. (revised 12/15/2008)

Parents/Guardians Signature ________________________________Date___________(Parents/Guardians' Signature is required if participant is under the age of 18)

Participant's Signature_____________________________________Date___________

(Participant's Signature is required)

NOTE: ATTACH A COPY OF YOUR INSURANCE CARD, FRONT AND BACK, TO EXPEDITE MEDICAL TREATMENT