Bitterroot Indoor Soccer Academy
2012
Sponsored by Ravalli Sports Club and Keystone Enrichment Program

                                                                                ****Please print off and mail in****

Student Information

Student Last Name:___________________________MI:_______First:____________________________

Gender (M/F):______Age:________Grade:________School:____________________________________

Guardian Information

Name:__________________________________Phone 1:_______________

Phone 2:________________

Best Method of Contact: Text____ Phone____
Email (provide)___________________________________

Permission
As the parent or legal guardian of __________________________________, I hereby give permission for my child to participate in the Bitterroot Indoor Soccer Academy sponsored by the Keystone Enrichment Program/Hamilton School District and Ravalli Sports Club. In consideration of the district’s agreement to allow my child to participate in the referenced program, I agree to accept responsibility for any loss, damage, or injury to my child that occurs during my child’s participation in this program that is not the result of fraud, willful injury to a person or property or the willful or negligent violation of a law by a trustee, employee or agent of the Bitterroot Indoor Soccer Academy.

By signing below, I am stating that I have read and understand the above.

______________________________________ _______________
Signature Date

Medical Release
I hereby authorize the staff of the Bitterroot Indoor Soccer Academy volunteers, coaches, trainers, supervisors, instructors and 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 or by licensed medical personnel. Staff will NOT medicate children. Parents/guardians are ENTIRELY responsible for medications and for personally arranging for or insuring the proper and timely medicating of their child.

Initial:_____

Picture Release
For internal and external use, I acknowledge that the Bitterroot Indoor Soccer Academy and/or its sponsors may utilize film, print, and digital images of a student or a family, which may be taken during involvement in the Bitterroot Indoor Soccer Academy activities. I consent to such uses & hereby waive all rights to compensation.

Initial:______