LOHS Youth Football Camp Registration Ages: 8-14 DATE: check back for new series in December 2023TIME: 9:30-11:30AM, CHECK IN AT 9COST: $20 (cash or check only).Please fill out this registration form prior to the camp date. RUDY BERUMENVARSITY HEAD COACH6001 Milliken Ave., RANCHO CUCAMONGA, CA 91730PHONE: 909.477.6900 EXT 2213EMAIL: coachberumen36@gmail.com By completing this registration form and participating in this camp you are agreeing to the following statement: I (your name), the parent or legal guardian of (your camper's name), grant the Los Osos High School Football Program my permission to use photographs from the LOHS Youth Football Camp for any legal use, including but not limited to: publicity, copyright purposes, illustration, advertising, and web content. IF YOU AGREEE TO THESE TERMS, CHECK YES AND CONTINUE WITH THE REGISTRATION. IF YOU DO NOT AGREE, YOU MAY EXIT THE FORM NOW. * yes Player NAME: * player age * T-SHIRT SIZE ... YSMALL YMEDIUM YLARGE YXLARGE Contact information Parent/Guardian First Name * First Name Last Name Parent/Guardian EMAIL address * Parent/Guardian PHONE number * (###) ### #### Emergency contact name * First Name Last Name emergency contact number * (###) ### #### WARNING, AGREEMENT TO OBEY INSTRUCTIONS, RELEASE, ASSUMPTION OF RISK AND AGREEMENT TO HOLD HARMLESS In consideration of being allowed to participate in the Los Osos HS Youth Football Camp, both the participant and the parent/guardian must carefully read and sign the agreement below. IMPORTANT: CURRENT HEALTH INSURANCE IS REQUIRED WHILE PARTICIPATING AS A MEMBER OF THE CAMP. INSURANCE VERIFICATION WILL BE REQUIRED AND MUST BE MAINTAINED THROUGHOUT THE DURATION OF THE CAMP. SIGNature * PLAYER ACKNOWLEDGMENT: I am aware playing or practicing to play/participate in any sport or other activity can be dangerous, involving MANY RISKS OF INJURY. I understand that the dangers and risk to play/participate in the Camp include, but are not limited to, death, serious neck and spinal injuries, which may result in complete or partial paralysis, brain damage, serious injury to vital internal organs, serious injury to virtually all bones, joints, ligaments, muscles, tendons and other aspects of the muscular, skeletal system, and serious injury or impairment to other aspects of my body, general health and well-being. I understand that the dangers and risk of playing or participating to play/participate in the athletic program may result not only in serious injury, but in a serious impairment to my future abilities to engage in other business, social and recreational activities, and generally to enjoy life. Because of the dangers of participating in the Camp, I recognize the importance of following instructions regarding techniques, training and other rules, and agree to obey such instructions. In consideration of the Camp permitting me to engage in all activities, I hereby assume all risks associated with participation and agree to hold the Camp, and the Chaffey Joint Union High School District, its employees, agents, representatives, coaches and volunteers harmless from any and all liability, actions, and cause of action, debts, claims, or demand of any kind and nature whatsoever which may arise by or in connection with my participation in any activities related to the camp(s)indicated on the Signature Page. The Terms hereof shall serve as a release and assumption of risk for my heirs, estate, executor, administrator, assignees, and all of the members of my family. I acknowledge that participating in any sport or other activity can be inherently dangerous and some activities can involve contact causing greater risk of injury. I also acknowledge that while this activity is taking place on the property of a Chaffey Joint Union High School District school site, it is not affiliated with or sponsored by the Chaffey Joint Union High School District. PLEASE TYPE CAMPERS NAME FOR ACKNOWLEDGEMENT. * signature * Parent Acknowledgement: I am the parent/legal guardian of the above participant. I have read the above warning and release and understand the activities associated with the sport or other activity mentioned above can involve risks of injury. In consideration of the Camp permitting my child/ward to engage in all activities, I hereby assume all risk associated with participation and agree to hold the Camp, and the Chaffey Joint Union High School District, its employees, agents, representatives, coaches and volunteers harmless from any and all liability, actions and cause of action, debts, claims or demand of any kind and nature whatsoever which may arise by or in connection with the participation of my child/ward in any activities related to the camp(s). The terms hereof shall serve as a release and assumption of risk for my heirs, estate, executor, administrator, assignees, and all of the members of my family. PLEASE TYPE PARENT'S NAME FOR ACKNOWLEDGEMENT. * SIGNATURE * CONSENT TO TREATMENT OF A MINOR: In such connection, we authorize such caring adult(s) to consent to X-ray examination, anesthetic, medical or surgical diagnosis or treatment, and hospital care to be rendered to such minor under the general or special supervision, and on the advice of a physician and/or surgeon licensed under the Medical Provisions Act, or to consent to any X-ray examination, anesthetic, dental or surgical diagnosis or treatment, and hospital care to be rendered to such minor by a dentist licensed by under the provision of the Dental Practice Act. If in another state or country, under the provision of the law in that state or country governing the practice of medicine. I also authorize care and prevention by the athletic trainer(s) and first aid by the assigned coaches. Whether on any such occasion such consent is rendered to any such medical or dental attention, it is to be considered within the above provision and limitation, under the same kind of circumstances within the full discretion, and in the course of the same kind of responsible deliberation as we as such minor’s parent and/or guardian would have considered it. We further authorize such caring adult to arrange for and hire ambulance or other emergency vehicle to transport, at our expense, such minor to a suitable place where medical or dental care is provided. PLEASE TYPE PARENT'S NAME FOR ACKNOWLEDGEMENT. * Signature * INSURANCE AFFIDAVIT: I/we the parent(s)/guardian(s), hereby declare that the health and injury insurance status of the Camp participant above is as follows: My Camp participant has medical insurance coverage for the duration of the Camp. I will maintain the insurance coverage and will notify the Camp immediately if the policy is cancelled or defaulted. * * yes no insurance company * policy number * ID# (If there is no ID #, retype the policy #) * Other information (i.e. known allergies). Type "NA" if there is no other needed info. * I acknowledge that this insurance information is true and correct. TYPE PARENT'S NAME TO ACKNOWLEDGE. * Thank you!
