Consent Form

TIM MARCUM FOOTBALL CAMPS

Your Subtitle text

Consent Form

Please right click on box below to print. Additional forms will be provided the day of camp. NOTICE: ALL ATHLETES WILL BE REQUIRED TO HAVE A SIGNED CONSENT FORM BEFORE TAKING THE FIELD.

Tim Marcum Football Camps
Parental Release – Physical Form
Waiver of Claims and Liability Release

PERSONAL INFORMATION: TO BE COMPLETED AND SIGNED BY THE CAMPER’S PARENT GUARDIAN

Session Attending: __________________

Athletes Name: _____________________________________                             Athlete’s age: ________

Athletes Address:____________________________________ City: _______________ State:_____ Zip: ___________

Mother’s Name: ____________________________ Home: (      ) __________________     Work: (      ) __________________

Father’s Name: _____________________________ Home: (      ) __________________     Work: (      ) __________________

Other Emergency Contacts

Name:_____________________________________ Relationship: _________________ Number: (      ) __________________

Name:_____________________________________ Relationship: _________________ Number: (      ) __________________

In consideration for acceptance as an Athlete in the Tim Marcum Football Camps (the “Camp”), the undersigned Athlete (“Child”) and Athlete’s parent(s) or legal guardian(s) agree to the following Waiver of Claims and Liability Release (“Waiver and Release”), which will cover events occurring from the time the Child commences participation in the Camp until termination of participation therein.

It is the intent of the undersigned Child and Child’s parents or legal guardians to release: the Camp, Arena Football League including but not limited to any teams, players and/or coaches participating, the United Football League including but not limited to any teams, players and/or coaches participating, all Tim Marcum Football Camps staff, the St. Pete Times Forum, Tampa Bay Arena, Tampa Bay Lightning , any participating agencies and each of their respective affiliates, officers, directors, employees, members, owners, volunteers, agents, corporate sponsors, and/or representatives (the “Camp Parties”) both as organizations and each person individually from any claims or liability to the fullest extent possible under the law of Florida, and to advance that intent the undersigned hereby agrees as follows:

1. I authorize the Child to participate in the Camp.

2. I acknowledge that the Camp will involve some physical activities that are strenuous and hazardous and I certify that the Child is in excellent physical health and has on physical limitations that would prevent the child from participating in the Camp. I grant permission to the Camp Parties to provide the Child with emergency medical treatment if needed. I further understand that should any medical services be provided or made available to the Child in connection with his participation in the Camp, the provision or availability of which the Camp does not sponsor or guarantee, the Camp does not warrant or make any representation concerning the adequacy or continuation of such medical services, nor can the Camp Parties be deemed responsible or held liable for any claims arising out of the provision of such medical services or the failure to provide or to continue to provide such medical services. I also understand that the Camp Parties cannot be held liable for any other services provided in connection with the Program, including without limitation any coaching, counseling, transportation, or security services.

3. I hereby indemnify, hold harmless and release Camp Parties for and from any and all liability for all claims, demands, losses, damages and costs including without limitation reasonable attorneys’ fees, fees that arise out of or in connection with any personal injury to the Child or others, sickness, accidents, delay, property damage, and/or other loss or expenses of any kind suffered by the Child in connection with the Child’s participation in the Camp.

4. I authorize the Camp Parties to take photographs and videotapes of the Child and to record the Child’s voice, conversation and other sounds during and in connection with the camp. I acknowledge that the Camp Parties shall own exclusively all copyright and other rights to such tapes, photography and recordings and may use them forever and throughout the world in any and all media, now known or hereby created, in connection with promoting or publicizing the Camp or any other endeavor without compensation to me or the Child. I authorize the Camp Parties to use the Child’s name, voice, likeness, image, photograph and any biographical facts provided to the Camp Parties in advertising and promoting the Camps or Camps programs throughout the country without further compensation.

5. I acknowledge that the Child’s participation in the Camp involves risk of serious bodily injury, death, and/or property damage. I assume and accept all risk of bodily injury, death, property damage and other harm connected with the Child’s participation in the Camp. I acknowledge that I am responsible for any and all medical expenses due to the Child’s illness or injury in connection with the Camp. OUR WAIVER AND RENUNCIATION OF CLAIMS IN THIS AGREEMENT EXPRESSLY APPLY TO ANY BODILY INJURY, DAMAGE, OR ACCIDENT THAT MAY BE SUFFERED BY PARTICIPANT OR OTHERS RESULTING FROM THE PARTICIPANT’S PARTICIPATION IN THE GAME OF FOOTBALL IN CONNECTION WITH THIS CAMP to the furthest extent possible under the law of Florida.

6. I understand and acknowledge that the Camp Parties do not guarantee the security or safety of Camp sites, of the areas adjacent to and surrounding Camp sites, or of any areas the Child may traverse on their way to or from camp sites. I release the Camp Parties from any and all claims arising out of accidents or events caused by a Child or third parties not associated with the Camp, which incidents could occur on Camp sites, in areas adjacent to or surrounding Camp sites, or in areas traversed by the Child traveling to our Camp sites. I further release the Camp Parties from liability for any damage or injury that may occur as a result of the surface or condition of the Camp site itself (e.g. the football playing field), or the condition of facilities or equipment used at the site.

7. I also agree to hold harmless the Camp Parties from any and all claims arising out of the equipment or uniform supplied to the Child for use in the Camp, or the equipment or other materials used by Camp staff in implementing the Camp.

8. I recognize that the Child must obey the instructions of coaches, their assistants, and any other camp staff, and we have instructed the Child to obey said coaches and other Camp staff. I understand and acknowledge that the Camp staff and Camp Parties reserve the right to terminate the participation in the Camp of any Child whose conduct may be considered by the Camp Parties, in their sole discretion, to be detrimental to or incompatible with the interests and security of the Camp. In the event of any such action by the Camp Parties, I understand and acknowledge that we will have no right to any compensation or damages from the Camp parties.

9. If any portion of this Waiver and Release is declared invalid or unenforceable by a final judgment of any court of competent jurisdiction, we hereby agree that such determination shall not affect the balance of this Waiver and Release, but this Waiver and Release shall remain in full force and effect, as such invalid portion shall be deemed severable.

10. We represent and confirm that the Participant has undergone a full and comprehensive physical examination administered by a Board-certified physician and on the basis of aforementioned physical examination that the Participant is physically fit to play the game of football and otherwise to participate in the Program.

11. I certify I am the parent or legal guardian of the Child should the child not be of legal age to sign this release and I, personally and on behalf of my child, acknowledge that I have read this Release, fully understand its contents and have signed below of my own free will.

Parent/Guardian Signature: _______________________________________ Date: ___________________

Print Name: _____________________________________

Please list any health problems or allergies we should be concerned with including previous significant injuries and/or allergies to medications:

______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

List all medications the camper takes and list what each medication is taken for: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

When was the camper’s last tetanus shot: _____/_____ (month/year)

Comments, concerns and/or explanations:

_______________________________________________________________________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________________________________________________

CONSENT FOR TREATMENT OF A MINOR

I, the undersigned, as parent / legal guardian of (camper) hereby authorizes such diagnostic, medical, and/or surgical treatment of such minor as may be considered necessary or appropriate under circumstances for the treatment of any illness or injury of the minor. The attending medical staff, and Tim Marcum Football Camps staff and, and employees shall not be responsible in any way for the consequences from said diagnostic, medical and/or surgical treatment and hereby released from any and all claims and causes of action that arise, grow out of, or be incident to such diagnosis, treatment, or surgery insofar as the law allows and provided that these services are performed with ordinary care to the best of their ability.

__________________________________________
Signature of Parent / Legal Guardian

_______________
Date

__________________________
Parent/Guardian Social Security #

__________________________________________
Insurance Company

__________________________________________
Policy Number

(_____)______________________________
Phone Number of Insurance Company