Camp Medical Form

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Child's Name* This field is required.
First Name
Last Name
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Child's Gender* This field is required.
Male
Female
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Child's Age* This field is required.
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Child's Date of Birth* This field is required.
Date
Year
Month
Day
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Parent's Name* This field is required.
First Name
Last Name
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Cell Phone* This field is required.
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Additional Parent/Guardian's Name
First Name
Last Name
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Cell Phone
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Emergency Contact* This field is required.
First Name
Last Name
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Emergency Cell Phone* This field is required.
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Medical Information* This field is required.1) Pediatrician's Name and Contact Info 2) Any recent injuries or illnesses of note 3) Allergy information and any treatment required. (EPI PEN, BENADRYL, ETC) Fastbreak Sports and employees will not dispense prescription medication
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Help us learn more about your child. How does your child do socially with peers? What are his/her likes and/or dislikes? Feel free to share anything about your child that will us help create more a comfortable environment for them.
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Waiver* This field is required.IN CONSIDERATION for being permitted to utilize the services, and programs of the FASTBREAK SPORTS LLC (the "FASTBREAK") and/or for my children listed above to so participate for any purpose, including, but not limited to, observation or use of facilities or equipment, or participation in any off-site program affiliated with the FASTBREAK. The undersigned, on behalf of himself or herself and such participating children and any personal representatives, heirs, and next of kin (hereinafter referred to as "the undersigned") hereby acknowledges, agrees and represents that he or she has inspected and carefully considered such premises, equipment and facilities and/or the affiliated program and that the undersigned finds and accepts same as being safe and reasonably suited for the use or participation by the undersigned and such participating children. In addition, the undersigned acknowledges that novel coronavirus (''COVID-19") infections have been confirmed throughout the United States. In accordance with the most recent guidance and protocols issued by the World Health Organization (WHO), the Centers for Disease Control and Prevention (CDC), the New York Department of Health, for slowing the transmission of COVID-19, the undersigned hereby agrees, represents, and warrants that neither the undersigned nor such participating children shall visit or utilize the facilities, services, and programs of the FASTBREAK (other than any exclusively online services and programs) within 14 days after (i) returning from highly impacted areas subject to a CDC Level 3 Travel Health Notice, (ii) exposure to any person returning from areas subject to a CDC Level 3 Travel Health Notice, or (iii) exposure to any person who has a suspected or confirmed case of COVID-19. The CDC Travel Health Network is continuously updating this list and the undersigned agrees that they are aware of this list and the countries listed. The undersigned agrees to check the CDC Travel Health Notices list (https://www.cdc.l!.ov/coronavirus/2019-ncov/travelers/index.html ) prior to utilizing the facilities, services, and programs of the FASTBREAK, on a daily basis if necessary. The undersigned hereby agrees, represents, and warrants that neither the undersigned nor such participating children shall visit or utilize the facilities, services, and programs of the FASTBREAK if he or she (i)experiences symptoms of COVID-19, including, without limitation, fever, cough or shortness of breath, or (ii) has a suspected or diagnosed/confirmed case of COVID-19. The undersigned agrees to notify the FASTBREAK immediately if he or she believes that any of the foregoing access/use restrictions may apply. The FASTBREAK has taken certain steps to implement recommended guidance and protocols issued by the Public Health Agencies for slowing the transmission of COVID-19, including, without limitation, the access/use restrictions set forth above. The undersigned acknowledges and agrees that the FASTBREAK may revise its procedures at any time based on updated recommended guidance and protocols issued by the Public Health Agencies and further agrees to comply with the FASTBREAK's revised procedures prior to utilizing the facilities, services, and programs of the FASTBREAK The undersigned further acknowledges and agrees that, due to the nature of the facilities, services, and programs offered by the FASTBREAK, social distancing of 6 feet per person among children and their caregivers in a childcare setting is not possible. The undersigned fully understands and appreciates both the known and potential dangers of utilizing the facilities, services, and programs of the FASTBREAK SPORTS LLC and acknowledges that use thereof by the undersigned and/or such participating children may, despite the FASTBREAK'S reasonable efforts to mitigate such dangers, result in exposure to COVID-19, which could result in quarantine requirements, serious illness, disability, and/or death. IN FURTHER CONSIDERATION OF BEING PERMITTED TO ENTER THE FASTBREAK SPORTS LLC FOR ANY PURPOSE INCLUDING, BUT NOT UMITED TO, OBSERVATION OR USE OF FACILITIES OR EQUIPMENT, OR PARTICIPATION IN ANY ON-SITE OR OFF-SITE PROGRAM AFFIUATED WITH THE FASTBREAK SPORTS LLC, THE UNDERSIGNED HEREBY AGREES TO THE FOLLOWING: THE UNDERSIGNED, ON HIS OR HER BEHALF AND ON BEHALF OF SUCH PARTICIPATING CHILDREN, HEREBY RELEASES, WAIVES, DISCHARGES AND COVENANTS NOT TO SUE the FASTBREAK SPORTS LLC, its directors, officers, employees, volunteers and agents from all liability to the undersigned or such participating children and all personal representatives, assigns, heirs, and next of kin of the undersigned or such participating children for any loss or damage, and any claim or demands on account of any property damage or any injury to, or an illness or the death of, the undersigned or such participating children ( or any person who may contract COVID-19, directly or indirectly, from the undersigned or such participating children) whether caused by the negligence, active or passive, of the FASTBREAK SPORTS LLC or otherwise while the undersigned or such participating children are in, upon, or about the premises or any facilities or equipment therein or participating in any program affiliated with the FASTBREAK SPORTS LLC. The undersigned expressly and knowingly waives all rights under California Civil Code Section 1542, which provides: "A general release does not extend to claims that the creditor or releasing party does not know or suspect to exist in his or her favor at the time of executing the release and that, if known by him or her, would have materially affected his or her settlement with the debtor or released party. "THE UNDERSIGNED HEREBY AGREES TO INDEMNIFY AND SAVE AND HOLD HARMLESS the FASTBREAK SPORTS LLC, its directors, officers, employees, volunteers and agents, and each of them, from any loss, liability, damages or costs they may incur, whether caused by the negligence, active or passive, or otherwise while the undersigned or any participating child is in, upon, or about the premises or any facilities or equipment therein or participating in any program affiliated with the FASTBREAK SPORTS LLC. The undersigned understands and agrees that the FASTBREAK SPORTS LLC is not required to provide insurance to cover the undersigned or such participating children in the event they suffer illness, injury, death, property loss, theft or damage of any sort upon, or about the premises or any facilities or equipment therein or participating in any program affiliated with the FASTBREAK SPORTS LLC. The undersigned agrees and acknowledges that use of the FASTBREAK SPORTS LLC facilities and services, and participation in the FASTBREAK SPORTS LLC programs, may involve inherent danger and risk, including, without limitation, the risk of physical illness or injury, death or property damage. THE UNDERSIGNED HEREBY ASSUMES FULL RESPONSIBIUTY FOR, AND RISK OF ILLNESS, BODILY INJURY, DEATH OR PROPERTY DAMAGE to the undersigned or such participating children due to negligence, active or passive, or otherwise while in, about or upon the premises of the FASTBREAK SPORTS LLC and/or while using the premises or any facilities or equipment thereon or participating in any program affiliated with the FASTBREAK SPORTS LLC The undersigned acknowledges that any illness or injuries that the undersigned or such participating children contract or sustain may be compounded by negligent first aid or emergency response of the Releasees and waive any claim in respect thereof. THE UNDERSIGNED further expressly agrees that the foregoing ASSUMPTION OF RISK, RELEASE AND W AIYER OF LIABILITY, AND INDEMNITY AGREEMENT is intended to be as broad and inclusive as is permitted by the laws of New York City and the State of New York and that if any portion thereof is held invalid, it is agreed that the balance shall, notwithstanding, continue in full legal force and effect. I HAVE CAREFULLY READ AND VOLUNTARILY SIGN THIS ASSUMPTION OF RISK, RELEASE AND W AIYER OF LIABILITY, AND INDEMNITY AGREEMENT AND FURTHER AGREE THAT NO ORAL REPRESENTATIONS, STATEMENTS OR INDUCEMENT AP ART FROM THE FOREGOING WRITTEN AGREEMENT HA VE BEEN MADE. I AM AW ARE THAT BY AGREEING TO THIS AGREEMENT I AM GIVING UP VALUABLE LEGAL RIGHTS, INCLUDING THE RIGHT TO RECOVER DAMAGES FROM THE FASTBREAK SPORTS LLC IN CASE OF ILLNESS, INJURY, DEATH OR PROPERTY WSS OR DAMAGE, INCLUDING, FOR THE AVOIDANCE OF DOUBT AND WITHOUT LIMITATION, EXPOSURE TO COVID-19 AT ANY FASTBREAK SPORTS LLC FACILITY OR PROGRAM AND ANY ILLNESS, INJURY OR DEATH RESULTING THEREFROM. I UNDERSTAND THAT THIS DOCUMENT IS A PROMISE NOT TO SUE AND A RELEASE OF AND INDEMNIFICATION FOR ALL CLAIMS. IF SIGNING ON BEHALF OF MINOR: I ALSO UNDERSTAND THAT THIS AGREEMENT IS MADE ON BEHALF OF MY MINOR CHILD(REN) AND/OR LEGAL WARDS AND I REPRESENT AND WARRANT TO THE FASTBREAK SPORTS LLC THAT I HAVE FULL AUTHORITY TO SIGN THIS AGREEMENT ON BEHALF OF SUCH MINOR(S). I have read and understand the terms of this Assumption of Risk, Release and Date Waiver of Liability, and Indemnity Agreement and agree to its terms.
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