JF Football

FCA Clinic Waiver

THIS FORM MUST BE FILLED OUT COMPLETELY AND GIVEN TO THE FCA PRIOR TO AN ATHLETE’S PARTICIPATION.

Dear Coach: Please

1)! Make copies for ALL participants 2) Have ALL participants complete this form 3) Keep copies of completed forms, return completed forms for ALL participants to FCA

Dear Parent/guardian: Please complete in full:

My child/ward has permission to participate in the 2012 FCA Sports Clinic (Clinic). I have no knowledge of any physical impairment that would affect or be effected by my child/ward participation in the Clinic. In the event of any emergency for which my child/ward requires medical attention, I authorize the staff of the Clinic to obtain for whatever treatment the staff, in its best judgment, deems necessary and appropriate. I specifically consent to such medical treatment and will be responsible for medical charges in connection with his participation in the Clinic. I specifically agree to waive and release the Fellowship of Christian Athletes (FCA), its employees, officers, or

agents from liability or any claim for damages which I or my child/ward has or may have against any facility, its owner/operator, program coordinator, coaches, or any other volunteer who participated in the Clinic. At times FCA will take pictures of or interview participants at Clinics and Ministry activities to share with the community as a way to promote the ministry. By signing below I give FCA the right to use a photo, electronic image or written representation of my child/ward in future promotional needs that would promote the FCA ministry.

Name of Sudent/Participant:________________________________Phone:_______________

Address:________________________________________ City:_________________ Zip:_______________

School:______________________________________________________________ Grade:________

Date of Birth:______________________________ Height:______________ Weight:____________

Parent/Guardian

Print Name:_____________________________________________________

Date:________________

Signature of parent or legal guardian (required)__________________________

PLEASE NOTIFY IN CASE OF EMERGENCY:

Father:__________________________ Employer:_________________

Day/cell Phone:___________________

Mother:_________________________ Employer:_________________

Day/cell Phone:___________________

INSURANCE COVERAGE:

Is your child/ward covered by insurance? Yes______ No_______

Insurance Company:__________________________________

Policy Number:______________________

FCA will have a secondary insurance coverage that, in effect, will pick up expense that your primary insurance does not cover, after you file a claim with your personal carrier. FCA has claim forms for you should the need arise.