ATHLETIC APPLICATION & WAIVER OF LIABILITY
Please circle the sport you would like your child to participate in:
Cheerleading Baton Twirling Soccer Football Volleyball Track Golf Basketball Baseball PE
Student’s Name_______________________________________ Age ____ Grade_____ Gender: ____ Date of Birth _________
Mother’s Name _______________________________Home Phone___________________ Work/Cell____________________
Father’s Name _______________________________ Home Phone ___________________ Work/Cell ___________________
Parent E-mail ____________________________ Student E-mail ____________________ Student Cell___________________
Address________________________________________________City_____________________St______ Zip____________
Person to Call in Case of Injury___________________________________ Relationship_____________ Phone____________
Family Doctor ______________________________________ Doctor’s Phone Number________________________________
Insurance Company______________________________ Policy Number___________________ Phone ___________________
Does this child have any disabilities, handicaps, present injuries or limitation, allergies, hemophilia, heart condition, history of
respiratory illness or any other significant medical condition? Please circle: Yes No If yes, please explain:
______________________________________________________________________________________________________
EMERGENCY AUTHORIZATION
I, the undersigned, parent or legal guardian of the participant, a minor, hereby authorize coaches, assistant coaches or parents of team members acting in the capacity of activity supervisors/vehicle drivers, as my Agents to consent to medical, surgical or dental examination and/or treatment. In case of emergency, I hereby authorize treatment, and/or care at any hospital. If there is an emergency and I cannot be reached, please contact the above emergency contact. I assume full financial responsibility for medical services rendered.
Signature of Parent or Legal Guardian _______________________________________________________________________
WAIVER OF LIABILITY, DISCLAIMER, AND PERMISSION
I, the parent or guardian of the above named individual, acknowledge that participation in athletic events necessarily involves risk of physical injury. I further acknowledge that the programs of Family Christian Academy are often times administered by parents, who volunteer their time, rather than by a paid, trained professionals. In consideration for accepting the registration of the named individual and permitting the voluntary participation or said individual in it’s programs, I (for myself as well as my child, his heirs and assigns) hereby release, discharge, and hold harmless Family Christian Academy and it’s employees, volunteers and other representatives or affiliates (including without limitation the participating churches, organizations participating through such churches, sponsors, game or event workers, officials, facilities and volunteers) from and against any and all claims arising out of or relating to illness, physical injury, death or other damages that may result to said individual while participating in a Family Christian Academy event. However, should officials, representatives or volunteers determine in their sole discretion that completion or participation in games or events would be injurious to my child’s health, or should my child become ill or injured, I consent to his or her removal and treatment by any physicians or medical care provider at the direction of the event or game officials, sponsors, representatives and/or volunteers. I give my permission for free use of my child’s name and picture in broadcasts, telecast or written accounts of any game, practice or participation in any Family Christian Academy sponsored event.
Parent/Guardian Signature____________________________________________________Date___________________________
Office Use Only: Size: T_____ B_____ Pay Method: _______Registration Fee: $______ Uniform Fee: $______
Total: $_______