ASA REGISTRATION APRIL 23 Form

Booking Form

Date: April 3rd 2023

Location: Fairlop Powerleague, Forest Road, IG6 3HJ

Time: 10am- 1pm

Price: £30

(On confirmation of the booking, payment details will be sent out).

**Cash is also accepted on the day**

Any further queries please do not hesitate to call/txt on 07837954460.

Player Information

Child's Name

First NameLast Name

Birth Date

MonthDayYear

Year Group (going into)

Gender

MaleFemale

Address

Street Address

Street Address Line 2

City

Post CodeCountry

Parent/Guardian Information

Name

First NameLast Name

Phone Number*

E-mail

example@example.com

Emergency Information

Emergency Contact's Name

First NameLast Name

Relationship

Phone Number*

Alt. Phone Number

Does the athlete have any allergies, chronic illness, or medical conditions? If yes, please describe.

Is the athlete prescribed an inhaler? If yes, please explain any instructions.

Informed Consent and Acknowledgement I hereby give my approval for my child’s participation in all activities prepared by ASA during the selected camp. In exchange for the acceptance of said child’s candidacy by ASA. In case of injury to said child, I hereby waive all claims against ASA,including all coaches and affiliates, all participants, sponsoring agencies, advertisers, and if applicable, owners and lessors of premises used to conduct the event. There is a risk of being injured that is inherent in all football activities, Some of these injuries include, but are not limited to, the risk of fractures, paralysis, or death.

Medical Release and Authorisation As Parent and/or Guardian of the named athlete, I hereby authorise the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed. Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunisations for the named athlete. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorisation is granted only after a reasonable effort has been made to reach me. Permission is also granted to ASA and its affiliates including Directors, Coaches, to provide the needed emergency treatment prior to the child’s admission to the medical facility. Release authorised on the dates and/or duration of the registered season. This release is authorised and executed of my own free will, with the sole purpose of authorising medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.

Confirmation BY ACKNOWLEDGING AND SIGNING BELOW, I AM DELIVERING AN ELECTRONIC SIGNATURE THAT WILL HAVE THE SAME EFFECT AS AN ORIGINAL MANUAL PAPER SIGNATURE. THE ELECTRONIC SIGNATURE WILL BE EQUALLY AS BINDING AS AN ORIGINAL MANUAL PAPER SIGNATURE.

Signature

FOOTBALL CAMP