Girls Football Trials Application Form

Girls Football Trials Application Form
Athlete Information
Childs Name*

First NameLast Name
Birth Date*

MonthDayYear
Age*
Ethnicity *
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Does you're child play Football*
If they play for a team please let us know which team
Primary position*
Is it a mixed or girls team?
Are they registered to an FA emerging talent (ETC)*
Are they registered to an Professional Game Academy*

Parent/Guardian Information
Name*

First NameLast Name
Best 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 any and all activities prepared by Back2Action during the selected camp. In exchange for the acceptance of said child’s candidacy by Back2Action ., I assume all risk and hazards incidental to the conduct of the activities, and release, absolve and hold harmless Back2Action . and all its respective officers, agents, and representatives from any and all liability for injuries to said child arising out of traveling to, participating in, or returning from selected camp sessions.

In case of injury to said child, I hereby waive all claims against Back2Action. 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 sports 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 immunizations 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 authorization is granted only after a reasonable effort has been made to reach me.

Permission is also granted to the Back2Action. and its affiliates including Directors, Coaches, and Team Parents to provide the needed emergency treatment prior to the child’s admission to the medical facility.

Release authorized on the dates and/or duration of the registered season.

This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence.
Image Consent

I declare that:

The name of the person in the photograph(s) is (the "Subject"); I hereby give my consent to the organisation for the use of images where the person subject is included therein, taken by the said organisation for production and use which the said person may appear in websites owned by the organisation, publications produced, print advertisements introduced by them.

In giving this consent, I understand and declare that:
- I am giving this consent in my own free will, and not under duress or in any form of threat.
- That the images containing the subject in this consent shall be held by the organization in accordance and compliance with the GDPR guidelines (the General Data Protection Regulation).
- That my information herein, as well as the images to be shared to the recipient shall not be disclosed to any other party without my written consent.
- That I hereby allow the use of images where the Subject is included shall belong to the organization for their own disposition.
- I hereby agree to waive my rights to any claims to whatever the organization may use of the image.
- I may exercise my right to withdraw the use of my image anytime after from the effectivity of this consent. After which, I am given the right to ask to cease the use of my images thereafter.
Person's Under the Age of 18 to be read and signed by Parent/Legal Guardian:

The name of the person in the photograph(s) is (the "Subject"); I hereby give my consent to the organisation for the use of images of my child/children where the child/children subject is included therein, taken by the said organisation for production and use which the said child/children may appear in websites owned by the organization, publications produced, print advertisements introduced by them.

In giving this consent, I understand and declare that:
- I am giving this consent in my own free will, and not under duress or in any form of threat.
- That the images containing the subject (child/children) in this consent shall be held by the organisation in accordance and compliance with the GDPR guidelines (the General Data Protection Regulation).
- That my child/children's information herein, as well as the images to be shared to the recipient, shall not be disclosed to any other party without my written consent.
- That I hereby allow the use of images where the Subject (child/children) is included shall belong to the organization for their own disposition.
- I hereby agree to waive my rights to any claims to whatever the organisation may use of the image.
- I may exercise my right to withdraw the use of my child/children's image anytime after from the effectivity of this consent. After which, I am given the right to ask to cease the use of my child/childrens images thereafter.
By submitting this form with my signature below, I am affirming to the provisions mentioned above and the effectivity of this agreement shall commence.
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.
Date*

MonthDayYear
Date
Signature*

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Girls Football Trials Application Form

Athlete Information