Aquaoaks Summer Camp Registration Form

Athlete Information

Athlete's Name*

First NameLast Name

Which day/s would you like to attend?*

Date Of Birth*

MonthDayYear

Gender

MaleFemale

Address

Street Address

Street Address Line 2

County

Post Code

Parent/Guardian Information

Name*

First NameLast Name

E-mail*

Phone Number*

Emergency Information

Emergency Contact's Name*

First NameLast Name

Relationship

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.*

Medical Release and Authorization

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 Aquaoaks Artistic Swimming Club and its affiliates including Directors, Coaches, and Team Managers 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 camp.

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.