H e n r y & c o o k s o c c e r • 7 5 W . 2 3 8 t h S t , • B r o n x , N Y 1 0 4 6 3 • 9 1 7 . 5 7 8 . 2 3 9 7

BERKELEY-CARROLL

AUGUST 17 – 20 At the DARROW SCHOOL - New Lebanon, NY

Cost: $750 per athlete

FALL PRESEASON SOCCER CAMP 2017

PIERRE COOK WAYNE HENRY

HENRY & COOK CAMPS INCORPORATED [75 West 238th Street, #4E, Bronx, NY 10463]

Camp Registration, Parental Consent and Liability Release Form

Last name: _________________________________ First name: ____________________________________ Age & Gender: ____________________________________ Shirt size: S M L XL Home address: ____________________________________________________________________________ Home & Cell Phones (H) ______________________ E-Mail address: __________________________________ (C) ______________________ E-mail address: __________________________________

Parent/Legal Guardian’s Name: ___________________________________________________________ Home Phone: ______________________________ Cell Phone: ________________________________ Name of Emergency Contact: ____________________________________________________________ Phone of Emergency Contact: ____________________________________________________________ Relationship to Camp Participant: _________________________________________________________

Health Insurance Company: ____________________________________________________________ Policy Number: ______________________________________________________________________ Name of Family Physician: ____________________________________________________________ Family Physician’s Contact Phone: _______________________________________________________ Food Allergies: ______________________________________________________________________ Drug Allergies: ______________________________________________________________________ Physical Handicaps: _________________________________________________________________ Other Medical Conditions: ____________________________________________________________ *please indicate if medication needs to be administered by ____________________________________________________________ the on-site trainer or medical personnel _____________________________________________________________

Participant Information

Parent/ Legal Guardian Information

Health Information

I hereby give consent for my child (named above) to participate in camp activities conducted by Henry & Cook Soccer Camp, Incorporated (H&CSC). While H&CSC staff will take every precaution to protect camp participants from injury, I understand that it is the nature of athletic activities that serious and disabling injury, including death, may occur. I also understand that participation in camp activities will require travel and that all travel involves similar risk of serious injury. I agree that my child must abstain from any and all alcoholic beverages and not to use any controlled substances for the duration of their trip. My child agrees to abide by the instructions and guidelines of the instructors/ chaperones at all times. I understand that breaking the terms of this contract means that my child may be sent home early from the camp at personal expense. Signing below acknowledges the terms and the adherence of this agreement. Parent/Legal Guardian Signature: _______________________________ Date: _______________

The undersigned and his or her parent/legal guardian hereby warrant that the above-named camp participant is physically fit and able to participate in all camp activities. The undersigned and his or her parent/legal guardian also authorize Henry & Cook Soccer Camp, Incorporated (H&CSC) staff to consent to any diagnostic procedure (including x-rays), to the administration of any medical or surgical treatment, or to any hospital care, when such treatment or care is administered by a licensed physician or medical facility. Parent/Legal Guardian Signature: ________________________________ Date: ______________ Camp Participant Signature: ____________________________________ Date: ______________

The undersigned and his or her parent/legal guardian hereby agrees to hold harmless Henry & Cook Soccer Camp, Incorporated (H&CSC), its employees, officers, volunteers, and agents harmless from any claims, damages, losses, and/or expenses arising from participation in camp activities and to assume all liability for any and all personal injury, bodily injury, illness, or property damage that occurs as a result of participation in such camp activities. Signature of this agreement also warrants that participation in this camp is voluntary, and that the undersigned and his or her parent/legal guardian have read this agreement and understands the risks inherent in the camp’s activities. All pictures or videos taken at camp may be used at the discretion of Henry & Cook. Parent/Legal Guardian Signature: _________________________________ Date: ______________ Camp Participant Signature: _____________________________________ Date: _____________

Parent/ Legal Guardian Consent

Authorization to Consent for Medical Treatment

Release of Liability