All Areas of This Form Must Be Completed and Signed Prior to Camp Participation
The George Tarantini Soccer School is not affiliated with NC State University

    _____  No  _____  Yes   Allergic reactions (drugs, food, asthma... ) If yes, list:   ____________________________
    ___________________________________________________________________________________________________________

    _____  No  _____  Yes  Taking any medication at this time?  If yes, list:  ___________________________________________
    ___________________________________________________________________________________________________________
    ___________________________________________________________________________________________________________

In Case of Emergency

I/We, the undersigned hereby certify that I (we) am (are) the parent of legal guardian of the camper.  I hereby give permission for the staff of the Camp to seek during the period of the Camp appropriate medical attention for the camper and for medical attention to be given and for the camper to receive medical attention in the event of accident, injury, or illness.  I will be responsible for any and all costs of medical attention and treatment, except for that covered by the camp's excess medical coverage policy.

I/We, the undersigned, for ourselves and as guardian(s) of   ____________________________________________
                                                                                                               Camper's Name

understand that soccer is an active, physical sport, and that injuries can take place during play.  I/We also understand there will be a number of children attending camp, there will be a limited number of coaches and / or counselors, and that our child can not receive individualized attention and supervision all of the time.  I/We understand that, as with any sport, injuries can occur, and we hereby acknowledge that our child is physically fit and mentally capable of participating in soccer and camp activities.

I/We, represent that I/We have sought the opinion of our child's pediatrician,  _____________________________________
                                                                                                                                Name of Camper's Physician
and he/she concurs that,  ________________________________________ is fully capable of safely engaging in these
                                                      Camper's Name
activities.  I/We also understand that it is my/our responsibility in caring for the camper listed above, to be assured that he/she is fully capable of engaging in this sport's activity, and I/we are confident that he/she is able to engage in such sport.

I/We, the undersigned for ourselves, our heirs, executors and administrators, waive, release and forever discharge the NC State Soccer Camp, and its staff, officers, agents, employees, representatives, successors and assign of and from all rights and claims for damages, injury, or loss to person or property which may be sustained or occur during particpation in Camp activities or while at Camp, whether or not damages, injury, or loss is due to negligence.

Signature of Parent or Guardian  ____________________________________________  Date:  ____________________________

Please fill out both sides of this form and return it with your deposit to reserve your space at camp.