Parental Consent Form (Print and return to team manager)

Consent Form pdf

To be completed in full by Parent or Guardian. No application can be accepted without the signature of a parent or legal guardian. This form is an agreement between signatory and Pete's Boots Camp at Clayton State University. Contact/Emergency Contact, Please print

I, acknowledge that I have read the release statement : Parent / Guardian Signature ___________________

Parent/ Guardian Printed Name __________________Date__________Relationship___________

Campers Last Name: _____________________________First Name________________________
Birthdat (MM/DD/YYYY)___________________________

Address: _____________________  ____City: ________________State: ____ Zip:___________
email: _________________________________________________
Phone: Home ___________________Work: __________________Mobile:__________________
Alternate Emergency Contact:
Full Name: _________________________________ Relationship: ________________________
Phone: Home ___________________Work: __________________Mobile:__________________

Family Doctor's Name____________________________Work Phone_____________________

Known Allergies________________________________________________________________

Physical concerns staff should be aware of___________________________________________

Insurance Company__________________________

Policy Holder________________________Policy Number____________________

MEDICAL RELEASE: I, ____________________________________ (Parent/Guardian Full Legal Name) hereby give permission for any and all medical attention to be administered to my child ___________________________________(Child’s Full Name)

Additional Information:

Team Name:_______________________ Playing Level (ie I , II , III)____________________

Position: (i.e. GK, Forward , Defender, Midfielder)___________________________________

T-Shirt Size (i.e. AS , AM , AL , AXL, AXXL) ____________