berks ajax parental consent form

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BERKS AJAX FC TRYOUT FORM Player Information Player’s Name _____________________________________________________________ Birth Date _________________________________________________________________ Age Level for Next Season 2015 - 2016

U12 - U13 - U14 - U15 - U16 - U17 - U18 (Please Circle)

Parent Information Parent’s Name ______________________________________________________________ Street Address ______________________________________________________________ City/State/Zip Code ___________________________________________________________ E-mail Address ______________________________________________________________ Home Phone __________________________ Cell Phone ____________________________

EMERGENCY CONTACT Name ______________________________________________________________________ Home Phone __________________________ Cell Phone _____________________________ Hospital preferred in case of emergency ___________________________________________ Allergic Reactions ____________________________________________________________ Taking any Medications ________________________________________________________ I/We the undersigned hereby certify that I/We am/are the parent or legal guardian of the above mentioned child. I/We hereby give permission to the staff of this tryout to seek during the period of the tryout appropriate medical attention for the player and for medical attention to be given and for the player to receive medical attention in the event of an accident, injury, or illness. I/We will be responsible for any and all costs of medical attention and treatment.

I/We, ______________________________the undersigned, for ourselves an as guardian(s) (Parent Signature)

of _____________________________ agree to these terms and understand the responsibility. (Player’s Name)