medical MEDICAL INFORMATION To provide your child with prompt medical by xuyuzhu


									                                                MEDICAL INFORMATION
To provide your child with prompt medical care, we must    I certify that_____________________________has my
have a completed consent form on file.                     permission to participate in the HUSA UNITED SOCCER ACADEMY. I
                                                           further certify that the above player has medical insurance in case
_________________________________________________          of injury or emergency. I hereby grant permission to officials of
Camper’s Name Birthday (M/D/Y)                             the HUSA ACADEMY to act for me according to their best judgment
                                                           in any emergency requiring medical attention. Furthermore, I
_________________________________________________          hereby waive and release HUSA UNITED SOCCER ACADEMY, its
Health Card Number                                         employees, agents, officers and staff for any accident or injury
                                                           sustained while at camp.
Allergies                                                  _________________________________________________
Known Allergies / Medical Conditions                       ACADEMY FEES
                                                           The fee for the duration of the academy is $175.00 for each
_________________________________________________          participant.
Medication Presently Taking
_________________________________________________          Complete the application and parental consent forms, and
Date of Last Tetanus Booster                               mail them with a check made payable to HUSA CONSULTING INC.
                                                           No telephone reservations will be accepted. All payments are due
                                                           no later than ________.
Does your child suffer from asthma?___________________
                                                           REFUNDS AND CANCELLATION POLICY

Does your child wear contact lenses?___________________    All campers who cancel, regardless of reason, will be re-
                                                           funded all pre-paid fees, except a $50.00 handling fee,
                                                           provided they cancel 10 days prior to camp. Any cancella-
List any recent injuries in the last 6 month:              tions within 7 days of camp will be assessed a $100.00
                                                           handling fee. No refund will be issued for cancellations
_________________________________________________          made within 24 hours of the start of camp for any reason.

List any medication the child takes on a regular basis:    CHECK IN/CHECK OUT
                                                           Campers will register between 12:00pm and 1:00pm. An all
_________________________________________________          camp meeting will be held at 2:30pm on the first day of
                                                           camp. The final session will be completed by 11:00am on
                                                           the last day of camp. Check out and a final all camp awards
EMERGENCY NUMBERS                                          ceremony will be held at 12:00pm on the final day of camp.
_________________________________________________          TRAINERS
Father’s Name                    Cell Number               A certified trainer will be on site to offer prompt attention
                                                           to minor injuries and ailments.
Mother’s Name                     Cell Number              SUPERVISION
                                                           All campers will be supervised by camp staff while participating in
_________________________________________________          HUSA United Soccer Academy.
Name and phone number to call if parents cannot be

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