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									         Chattanooga Player Development Soccer Academy
                        June 18 - 21, 2012
                     Redoubt Soccer Complex
                         Medical Release & Information

Medical Insurance Company Name _____________________________________
Policy Number ___________________________________

In an emergency, if parents cannot be reached please notify:
       Name __________________________________________
       Relationship _____________________________________
       Phone Number ___________________________________
       Cell Number _____________________________________

Family Doctor ____________________________________
Phone Number ___________________________________
Known Allergies __________________________________
Asthma _______________ Diabetes ___________________
List of Medications currently taking __________________________________________

I, the undersigned, hereby certify that I am the parent or legal guardian of the above
camper. I hereby give permission for the Camp Staff to seek during the period of the camp
appropriate medical attention for the camper and for medical attention to be given in the
event of accident, injury, or illness. I will be responsible for any and all costs of medical
attention and treatment. I the undersigned for myself and as guardian of the above camper
understand that soccer is an active, physical sport, and that injuries can take place during
play. I also understand that, as with any sport, an injury can occur, and I hereby
acknowledge that my child is physically fit and mentally capable of participating in soccer
and all camp activities. I represent that I have sought the opinion of my child’s pediatrician,
and he/she concurs that the above camper is fully capable of safely engaging in these
activities. I the undersigned for myself, my heirs, executors and administrators, waive,
release and forever discharge John Millard, Chattanooga Player Development Academy 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 participation in camp activities or while at camp, whether or not damages,
injury, or loss is due to negligence. I grant permission to the Chattanooga Player
Development Academy and its agents or employees to use photographs or images taken of
the above camper for publication in camp publications such as camp brochures, social
media sites, promotional material, newsletters, and magazines, and to use the photos on
websites, and to offer them for publications without notifying me.

__________________________________________________________ __________
Parent or Guardian signature                                   Date

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