Blake Levine Youth Soccer Camp

INSURANCE AND LIABILITY WAIVER & CONSENT FORM

• I understand that I am required to have accidental medical coverage for the child listed on this waiver, and I verify that the information provided on this form is accurate and true.

• I understand and agree that if I do not have accidental medical coverage for the child listed on this waiver, I will be financially responsible for all charges and fees incurred in the rendering of said treatment.

• I understand that at the discretion of the camp supervisor and staff my child may be

• dismissed from the camps without refund for inappropriate behavior.

• I understand that at the conclusion of the scheduled camp time the program and staff

• are no longer responsible for my child.

• I give permission to use, reprint and produce any photographs or videos taken of me or

  my child and written materials supplied by me or my child in the form of evaluation

  during the youth sports program.

• I hereby authorize the Blake Levine Youth Soccer Camp staff to act for me in case an

  emergency and waive and release Blake Levine Youth Soccer Camp from any and all liability for any and all injuries and illness occurred while at camp.

• By completing registration & typing my name abovce I agree to the terms above.

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