JOÜK Winter 2024/2025 Soccer Registration

Centaurus FC Summer '25 International Camp at PSG - Registration and Medical Form (For Parents/Guardians)
Please submit one registration and medical form per camper, before June 1st, 2025. The Physical Examination Form is separate and may be filled out directly by the child's physician by June 15th.
*** Please print the Physician's Physical Examination Form from this link ***
Camper Information
Camper's Name

First and Middle NameLast Name
Birth Date

MonthDayYear
Grade most recently completed at school
Home Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Parent/Guardian 1 Information
Name

First NameLast Name
Phone
E-mail
example@example.com
Parent/Guardian 2 Information
Name

First NameLast Name
Phone Number
E-mail
example@example.com
Additional Emergency Contact Information (2 Required)
Emergency Contact's Name

First NameLast Name
Relationship
Phone Number
Emergency Contact 2's Name

First NameLast Name
Phone Number
Relationship
CLOTHING SIZE (for Centaurus and PSG uniforms)

Youth SmallYouth MediumYouth LargeYouth XL
Primary Care Physician/ Pediatrician Information:
Doctor's Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Immunizations

Please indicate the most recent dose, with month and year, for each immunization.

	MONTH	YEAR
DTaP (Diptheria Tetanus and Pertussis)
Hepatitis B
HIB (Haemophilus Influenza Type B)
MMR (Measles Mumps Rubella)
Varicella (Chicken Pox)
PCV (Pneumococcal Conjugate)
Polio
COVID-19

Allergies and Dietary Requirements

Campers will be provided 3 healthy athletic meals daily (and snacks on training days) at either the Paris Saint-Germain training facility or the Île de Loisirs multisport complex. In order to plan ahead, please tell us about any camper food allergies or special dietary requirements/restrictions here.
My camper:

Can eat meals as prepared (no restrictions/allergies)Has a food allergyHas a dietary restriction due to culture or religionHas a health related dietary restriction
Please explain any dietary restriction or requirement here (foods the child should not eat, subsititutions, etc.)

PLEASE EXPLAIN ANY MAJOR ALLERGIES HERE (TO FOODS, MEDICATION, ENVIRONMENTAL ETC.):

	Substance	Severe? (anaphylaxis)	Epi-pen needed?	Treatment?	Needed Restrictions (avoid...)
Allergy 1
Allergy 2
Allergy 3
Allergy 4

***Will your child need to bring an Epi-pen to camp? If so, please speak directly to Coach Walter to arrange details.

YESNO
Medical Conditions

Please check any medical condition that applies to your child and explain any treatment needed during camp.

	Yes	Requires Treatment During Camp	Describe treatment needed (medication, etc.)
Contact Lenses or Glasses
Asthma
Hard of Hearing/Deaf
Recent Injury
Seizure Disorder
Allergies (see form above)
Diabetes
Heart Condition
Digestive Issues
Joint Problems
Skin Problems
Any Activity Restriction
High Blood Pressure
Orthodontic Devices
Any other illness

Mental/ Emotional/ Social Health

Please check any mental health or emotional/social condition that camp staff should be aware of, and explain any treatment needed during camp.

	Yes	Requires Attention During Camp	Describe attention or treatment needed (medication, precautions, etc.)
Depression
Anxiety
ADHD
ASD
Recent trauma/ other significant event
Sleep issues (insomnia, sleepwalking, etc.)
Any other condition

Medications

PLEASE READ: PRESCRIPTION MEDICINES: All camper prescription medications must be sent in their original container marked with a pharmacy label including the name and number of the prescribing physician and dosage/frequency, with sufficient medicine for the camp period. Medicines used on an "as needed" basis such as inhalers must also be labeled with the dosage and frequency. OVER THE COUNTER (OTC) MEDICINES: Must be provided in their original container and also be labeled with specific instructions for use (Child’s name, dosage amount and frequency, prescribing practitioner). ***All medications should be handed in directly to camp staff, for proper storage and administration.
Will your child need to use any prescription medication while at camp?

YesNo
Will your child need to bring any over-the-counter medication for use while at camp? (for example, Pepto-Bismol, Sudafed, Tylenol, etc.)

YesNo

Please specify details about any medications:

	Name of Medication	Dosage and Frequency	Condition treated	Refrigerated?	How to administer
Medication 1
Medication 2
Medication 3
Medication 4

Is your child allergic or otherwise intolerant to any medications?

YesNo
If so, please specify which medication:

Please check whether it is ok for camp staff to administer the following first aid medications and/or preventive care to your child as needed while in France:

	Yes	No	Any comment
Sunscreen
DEET Insect Repellent (Off, etc.)
Tylenol (acetaminophen)
Anti-fungal cream (athlete's foot cream)
Antiseptic spray
Caladryl or hydrocortisone cream (anti-itch)

Please write any further information about your child's health, wellness, and behavior that you think would be helpful for camp staff to know here:
Insurance Information
Insurance Company

CompanyPolicy and Group Number
Insurance Company Address

Claims AddressClaims Phone #
Name of Insured

NameRelationship to Camper
France's public health system does not cover emergency/urgent care medical expenses for American travelers. Please check one of the following boxes to answer this question: How would you cover emergency or urgent care medical costs for your child, should any arise, in France?

My U.S. insurance offers overseas coverageI plan to purchase travel health insuranceI plan to pay out of pocket for any emergency medical expense
Camp Fee Schedule
A non-refundable deposit of 40% ($1120) is due before Feb. 7th, 2025, and the remainder of the camp fee on April 12th ($1680). Please check the method you will use to make a deposit. *Note: after submitting this form, you will receive an invoice.

Venmo (@waltamirano)Zelle (jouk.soccer@gmail.com)Paypal (jouk.soccer@gmail.com) -- See QR code below + please add a 3 % processing fee if using Paypal
Release and Waiver of Liability

By selecting agree below submitting this online form by hitting the “SUBMIT” button below, which constitutes my electronic signature, I acknowledge and agree as follows:
1. I permit my child to fully participate in the voluntary activities sponsored by Joük, LLC (the “Program” or “Joük”), Centaurus FC, Paris Saint-Germain Football Club, and the Île de Loisirs deVaires-Torcy sports complex and housing.

2. I acknowledge, agree and represent that I understand the nature of the activity and that my child is qualified, in good health and in proper physical condition to participate in such activity, and that I have filled out the above information truthfully and to the best of my knowledge. I further agree and warrant that if at any time I believe conditions to be unsafe for my child to participate, I will immediately discontinue my child’s further participation in the activity.

3. I FULLY UNDERSTAND that: (a) ATHLETIC ACTIVITIES INVOLVE RISKS & DANGERS OF SERIOUS INJURY, INCLUDING PERMANENT DISABILITY, PARALYSIS, & DEATH (“RISKS”); (b) these Risks may be reduced by particular rules, equipment, & personal discipline, however the risk of serious injury does still exist; (c) these Risks & dangers may be caused by my own actions or inactions, the actions or inactions of others participating in the activity, the condition in which the activity takes place, or THE NEGLIGENCE OF THE “RELEASES” NAMED BELOW; (d) there may be OTHER RISKS AND SOCIAL AND ECONOMIC LOSSES either not known to me or not readily foreseeable at this time, and I KNOWINGLY, FREELY, AND FULLY ACCEPT AND ASSUME ALL SUCH RISKS AND ALL RESPONSIBILITY FOR LOSSES, COSTS, AND DAMAGES my child incurs as a result of his or her participation in the activity.

4. While staff have safety protocols in place to manage allergen related issues, I understand that a minor with specific allergies or intolerances has a role and responsibility in the avoidance of the known allergen. I agree to educate my child, who has allergies or intolerances, to ask questions, read labels, or abstain from the substance in question when in doubt.I hereby give permission to the camp to provide basic first aid, and administer prescribed medications as authorized by my child's PCP. I also give permission for Joük staff to administer camp stocked over-the-counter medications and preventives on an "as needed" basis, as indicated on this form. I give permission to Joük to seek emergency medical treatment including ordering x-rays, anesthesia, or routine tests. In the event of an emergency, I give permission to the camp to arrange necessary related transportation for my child. In the event I cannot be reached in an emergency, I hereby give permission to the practitioner selected by the camp to secure and administer treatment, including hospitalization, for my child, understanding that every effort will be made by camp staff to reach me in the event of an emergency and of any illness/injury.

5. I, for myself and on behalf of my participating heirs, assigns, personal representatives and next of kin, HEREBY RELEASE AND HOLD HARMLESS Joük, their officers, members, managers, officials, agents, and/or employees, coaches, directors, volunteers, other participants, sponsoring agencies, sponsors, advertisers, and if applicable, owners and lessors of premises used to conduct the events (“RELEASES), WITH RESPECT TO ANY AND ALL INJURY, DISABILITY, DEATH or loss or damage to person or property, WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASES OR OTHERWISE, to the fullest extent permitted by law.

6. I certify that I, as parent/guardian with legal responsibility for the minor participant, do consent & agree to his/her release as provided above of all the releasees, and for myself, my heirs, and next of kin, I release & agree to indemnity and hold harmless the Releasees from any and all liabilities incident to my minor child’s involvement or participation in these programs as provided above, EVEN IF ARISING FROM THEIR NEGLIGENCE, to the fullest extent permitted by law.

7. I hereby authorize Joük to allow the reproduction, dissemination, and/or publication of my child's name and likeness for media coverage, public relations, or any other purpose which may involve the use of photographs, films, and/or video tape recording. This is to be done in conjunction with my participating in the Program, and I understand and agree that I may neither pay a fee to receive individual promotional consideration from my participation in this program, nor will I receive payment for the possible commercial use of my name or likeness.
AgreeDisagree
I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT.
Signature Date

MonthDayYear
Date
Electronic Signature (Type your full name here)
Should be Empty:

Centaurus FC Summer '25 International Camp at PSG - Registration and Medical Form (For Parents/Guardians)

Please submit one registration and medical form per camper, before June 1st, 2025. The Physical Examination Form is separate and may be filled out directly by the child's physician by June 15th.

Primary Care Physician/ Pediatrician Information:

Immunizations

Allergies and Dietary Requirements

Medical Conditions

Mental/ Emotional/ Social Health

Medications

Insurance Information

Camp Fee Schedule