Camp Location: SOMERSET CO, NJ
Player Information
& Medical Waiver form
DATES: JUNE 29-30
Player Information
Please complete ALL fields
Sizes run big - please choose
1 size smaller for snug fit
Athlete’s Name:
Age:
Shirt size:
M
L
XL
Parent’s Email:
Your School Name:
XXL
XXXL
1
Head Football Coach:
Position(s):
Address:
City:
State:
Phone: (
)
Alternate Phone: (
Emergency contact/Insurance Information
Emergency Contact:
Zipcode:
)
Please complete ALL fields
Phone: (
2
)
Person to contact if unable to reach parents:
Relationship:
Phone: (
)
Health Insurance Provider:
Policy #:
Preferred Hospital:
Personal Physician:
Medical Questions
Physicia n’s Phone: (
Please answer ALL questions
1. Do you have Diabetes? . . . . . . . . . . . . .
YES
NO
If yes, give insulin dosage:
2. Do you have Epilepsy? . . . . . . . . . . . . .
YES
NO
YES
NO
4. Any other health problems? . . . . . . . . . . .
YES
NO
If yes, please explain:
5. Are you allergic to any medications? . . . . . .
YES
NO
6. Are you allergic to insect stin gs? . . . . . . . .
If yes, what does your doctor recommend?
YES
NO
7. Do you have Asthma? . . . . . . . . . . . . . .
If yes, what does your doctor recommend?
YES
NO
If yes, give medication:
3. Do you have Heart Disease? . . . . . . . . . .
If yes, please explain:
If so, what?
8. Date of last tetanus shot:
)
/
/
3
Consent Information Please initial all section
4
Release – Minor’s Rights
In consideration of Nzone Football LLC Camps allowing the aforementioned player to participate in the Nzone Football
LLC Camp identified on page 1, I, the undersigned Parent/Guardian, In consideration hereby release and hold
harmless , Zoran Milich, SOMERSET COUNTY PARK COMMISSION, of, members of its board of directors, and
its officers, employees, members, volunteers, other participants, and agents (collectively, the “Released
Parties”), of and from, and do discharge and waive, any and all claims, demands, losses, damages, and
liabilities that Minor Participant may have or sustain with respect to any and all damage and/or injury, or any
type, arising out of his or her participating in the Camp. Parent Initials
Release – Parents’/Guardians’ Rights
In consideration of Nzone Football LLC allowing Minor Participants to participate in the Nzone Football LLC Camp
identified on page 1, I, the undersigned Parent/Guardian, hereby release and hold harmless the Released
Parties, of and from, and do discharge and waive, any and all claims, demands, losses, damages, and liabilities
that I may have or sustain with respect to any and all damage and/or injury, of any type, arising from minor
Participant’s participation in the Camp. Parent Initials
Indemnification by Parent/Guardian:
In consideration of Nzone Football LLC Camps allowing Minor Participant to participate in the Nzone Football LLC
Camp identified on page 1, I, the undersigned Parent/Guardian, agree to indemnify, save and hold harmless the
Released Parties from any and all claims, demands, losses, damages and liabilities for indemnities, contribution or
otherwise with respect to any damage and/or injury, of any type, arising from Minor Participant’s participation in
the Camp. Parent Initials
Emergency Medical Treatment
In case of a medical emergency, I give Nzone Football LLC Camps, Zoran Milich, medical training staffs
my permission to perform or to sign for any medical assistance, which may be deemed necessary. Parent Initials
Behavior Policy
The undersigned Parent/guardian acknowledges and agrees that if Minor participant becomes a problem or
violates camp rules or is involved in any other on campus violation, he will be sent home at my expense. Nzone
Football LLC Camps, Zoran Milich, SOMERSET COUNTY PARK COMMISSION, are not responsible for
supervision of players/campers who choose not to participate on the football fields. Parent Initials
Weather Policy
No refunds will be given for practices delayed or cancelled due to adverse weather conditions. Parent Initials
Parent/Guardian Printed Name
Payment Options
Payment Option 1:
Early Registration $190 per player: Due June 1, 2015
Late Registration: $210 :
Make check payable to Nzone Football LLC
and attach to registration form.
Please Option 2:
Please charge my card:
card #
Submit the Registration form to the following:
expiration date
Mail:
name on card
Attn:
Nzone Football
125 30th st.
Heromosa Beach, CA 90254
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cvv code
Signature @@@@@@@@
Address:
Street
City
Camp fees must be paid prior to beginning of camp.
State
Zip
5