MINOR GENERAL RELEASE AND HOLD HARMLESS AGREEMENT I am the parent or legal guardian of the “minor”, who desires to participate in the Northview Soccer Camp (hereinafter collectively referred to as the “Activities”) operated or sponsored by Northview Community Church (hereinafter referred to as the “Church”). I understand and acknowledge that the Church will not allow the minor to participate in the Activities without releasing and holding the Church harmless from any liability arising out of the minor’s participation in the Activities. I have investigated the risks involved in the minor’s participation in the Activities and fully understand and assume such risks on his or her behalf. Specifically, I understand and acknowledge that the minor may suffer or experience, among other things, personal injury or bodily damage, medical disabilities, loss or theft of personal property, imprisonment, abduction and even death. I request that the church allow the minor to participate in the activities, and in consideration thereof agree hereby to release and forever discharge the church, its officers and directors, and its employees, agents, and any parties volunteering on behalf of the church, from all actions causes of action, injuries, claims, damages, costs or expenses of any kind growing out of or related to any such activities in which the minor participates. I understand that this is a full and complete release of all injuries and damages which I or the minor may sustain as a result of his or her participation in any activities, regardless of the specific cause thereof. I further acknowledge and agree that I have given my consent for the minor to remain in the custody of the Church’s representatives while participating in the Activities. This Agreement is binding on the minor’s heirs, successors, and personal representatives. NORTHVIEW SOCCER CAMP - JULY 13 - 17, 2015 - VIDEO/STILL PHOTOGRAPHY AUTHORIZATION I hereby authorize staff of Athletes in Action, Northview Community Church or Abbotsford Food Bank to take video and still photos of my child during camp. These videos and still pictures may be used on website and marketing materials as well as youtube and facebook promotions. I understand they retain the sole right to use photos and video for publicity and advertising purposes only. MEDICAL TREATMENT AUTHORIZATION & POWER OF ATTORNEY In the event the minor suffers an injury or condition during his or her participation in the Activities, including transportation to and from the Activity, which may endanger his or her life, cause disfigurement, physical impairment, or undue discomfort if medical treatment is delayed, and reasonable attempts to contact me and my spouse have been unsuccessful, I hereby appoint a Northview and or Athletes in Action Representative, to make an informed decision regarding such treatment, I hereby appoint the Northview and or Athletes in Action Representative as my agent to act for me and in my name (in any way I could act in person) to make any and all decisions for the minor concerning his or her personal care, medical treatment, hospitalization and health care. This power of attorney and delegation of authority shall terminate when the agent is first able to contact me or my spouse. This information is for the sole use of Northview Community Church. I hereby give permission for the child named on this registration to participate in the Northview Soccer Camp. I have read and understood the legal information on this page. ____________________________________________ Signature of Parent/Guardian – Date CONTACT: Northview Community Church: Carrie at [email protected] OR Abbotsford Food Bank: Brad at [email protected] IN PARTNERSHIP WITH: Become a total athlete! AIA’s university, college and club soccer players will help your child develop fundamental dribbling, shooting, passing and ball control skills. Each day includes exciting competitions and fun tournaments. Every camper gets the individual attention they need to grow physically, socially, mentally and spiritually. WHAT TO BRING: • 2 Water Bottles (freeze one ahead of time) • Shorts and T-shirt (no jeans please) • Cleats (not mandatory) • Sweater/jacket/rain gear • Sunscreen • Hat **PLEASE NOTE: Lunch will be provided for all campers, however, we are unable to accommodate dietary restrictions. If necessary please send your child with a bag lunch and drop it off at the Hospitality Tent. SCHEDULE: 9:00 Introduction 9:10 Warm Up 9:25 Group Game 9:45 BREAK 10:00 Fast Footwork 10:25 Skill Stations 11:30 Coach’s Corner 12:00 LUNCH Included** 1:00 Juggling 1:20 Euro Cup 1:45 BREAK 2:00 World Cup 2:45 Wrap Up 3:00 Home Time 32040 Downes Road Abbotsford, BC V4X 1X5 (604) 853-2931 "– – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – – LOCATION: Ridgeview Park, Vantage Place, Abbotsford DATE: July 13-17, 2015 TIME: 9 AM to 3 PM AGES: 6 to 14 PRICE: $125 ($115 Before June 1, 2015) *$25 non-refundable cancellation fee if cancelled after June 14, 2015 NORTHVIEW SOCCER CAMP REGISTRATION FORM Please fill out this form, detach and return it to Northview or the Abbotsford Food Bank, along with your registration fee by June 1, 2015, to reserve your spot! Cheques payable to Northview Community Church. REGISTRATION: FOOD BANK CLIENTS PLEASE CONTACT BRAD at 604-859-5749 or by email [email protected] $115.00 per camper $125.00 if registering after Monday, June 1, 2015. Child’s Name (first and last):______________________________________________________ Age: ________ Address: ________________________________________________________________________________________________ Postal Code_________________________ o Male o Female Birthdate:_____________________ T-shirt size(circle one): YS YM YL S M L Current School: ______________________ Parent/Guardian Name(s): _____________________________________________ Phone Number: ______________________Email Address: ________________________ Emergency Contact (Name): ________________________________________________ Emergency Contact (Phone #): _____________________________________________________________________ Child’s Care Card Number: __________________________________________________________________________ Does your child have any allergies or dietary restrictions? _______________________ ___________________________________________________________________ Please list any medications currently being used: _______________________________________________ Does your child have a designated disability or delay? Yes No Does your child qualify to receive one on one assistance at school? Yes No Has your child experienced: Seizures, Neck Problems, Back Problems, Fainting Spells, Heart Problems, Nose Bleeds or Asthma? _____________________________________ Has your child experienced in the last year: Head Injury, Major Surgery, Overuse Injury, Fractures? ______________________________________________________________ Other important information we should know about your child:_______________________ _______________________________________________________________________ Pick up authorization (other than Guardian) Name:______________________________ Will your child have transportation to and from camp? ____________________________ Amount Paid ______________________ Method of Payment _____________________ My child would also like to participate in the Mini World Cup on Monday June 29th. Y N
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