2021 Boys SAQ Clinic Registration
Player's Full Name
Emergency Contact Phone
Existing Medical Coverage
Medical Plan #
I hereby voluntarily permit me or my child to participate in the SAQ Clinics. I UNDERSTAND AND FULLY ACCEPT THAT THERE ARE RISKS INVOLVED IN SPORTS, AND THAT ACCIDENTS AND INJURIES ARE COMMON AND ARE ORDINARY OCCURRENCES OF SPORTS. I HEREBY AGREE TO ACCEPT ANY AND ALL RISKS OF INJURY, AND VERIFY THIS STATEMENT BY PLACING MY INITIALS HERE:
As consideration for being permitted by Fairfield County Soccer Academy (FCSA) to participate in these activities, I hereby release and hold harmless FCSA, staff, volunteers, designated coaches, and program officials from all liability, and from all actions or claims that I or my child now or hereafter have for damage or injury to me or my child, or to any person or property, resulting from the negligence or other acts of any employees or volunteers in connection with me or my child’s participation. I further agree that this waiver, release and assumption of risks is to be binding on the heirs and assigns of the undersigned. I further agree to indemnify and to hold FCSA (its officers, employees, agents and volunteers) free and harmless from any loss, liability, damage, cost or expense which they may incur as a result of any injury and/or property damage that I or my child may cause or sustain while participating in this activity. In case of a medical emergency, I hereby give permission to FCSA Staff, Trainers and Volunteers to order treatment for me or my child, including any necessary medical treatment and x-rays. I also hereby give permission to FCSA Staff and Volunteers to disclose the information contained on this form to medical personnel. I understand that an attempt will be made to reach me by phone when a diagnosis is completed. I agree to pay all medical, hospital, or other expenses which my child or I may incur as a result of such treatment. FCSA also does not provide any medical or other insurance protection or benefits for those who participate in the SAQ Clinics. I HAVE CAREFULLY READ THIS RELEASE AND FULLY UNDERSTAND ITS CONTENTS. I AM AWARE THAT THIS IS A RELEASE OF LIABILITY AND A CONTRACT BETWEEN ME AND FAIRFIELD COUNTY SOCCER ACADEMY AND SIGN IT OF MY OWN FREE WILL. Please type your full name to sign agreement electronically.
The novel coronavirus, COVID-19, has been declared a worldwide pandemic by the World Health Organization. COVID-19 is extremely contagious and is believed to spread mainly from person-to-person contact. As a result, federal, state, and local governments and federal and state health agencies recommend social distancing and protocols to mitigate the spread of COVID-19. FCSA will put in place preventative measures to reduce the spread of COVID-19; however, we cannot guarantee that you or your child(ren) will not become infected with COVID-19. Further, attending the clinic could increase your risk and your child(ren)’s risk of contracting COVID-19. By signing this agreement, I acknowledge the contagious nature of COVID-19 and voluntarily assume the risk that my child(ren) and I may be exposed to or infected by COVID-19 by attending the clinic and that such exposure or infection may result in personal injury, illness, permanent disability, and/or death. I voluntarily agree to assume all of the foregoing risks and accept sole responsibility for any injury to my child(ren) or myself (including, but not limited to, personal injury, disability, and/or death), illness, damage, loss, claim, liability, or expense, of any kind, that I or my child(ren) may experience or incur in connection with my child(ren)’s attendance or participation in the clinics, leagues or camps run by FCSA.
Cost of the clinic is $65.
Your registration is NOT COMPLETE until online payment is submitted on the next page.
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