Middlebury

Middlebury College Women's Soccer Clinic/Camp Sign-up Form

The Registrant recognizes that the games of soccer and associated training are physical activities during which injuries may occur. I certify that my child is in good physical health, and has my permission to participate in Panther Soccer Academy programs. I hereby release and indemnify Panther Soccer Academy, Middlebury College and their affiliated organizations, sponsors, directors, employees, and volunteers from any liability claim on behalf of the registrant.

As the player's parent/guardian, I request that in my absence the above-named player may be admitted to any hospital or medical facility for diagnosis and treatment. I request and authorize physicians, dentists, and staff, duly licensed as Doctors of Medicine or Doctors of Dentistry or other such licensed technicians or nurses, to perform any diagnostic procedures, treatment procedures, operative procedures and x-ray treatment of the above minor. I have not been given a guarantee as to the results of examination or treatment. I authorize the hospital or medical facility to dispose of any specimen or tissue from the above-named player.

By checking the box above, I agree to the terms of the Panther Soccer Academy Release Statement.