Tampa Elite Soccer Academy

Tampa Elite Soccer Academy

Release, Consent, and Emergency Authorization Form

Camper Name:
Parent/Guardian Name:
Address:
City:
County:
State:
Zip:
Tampa Elite Soccer Academy Release, Consent and Emergency Authorization form In consideration of being allowed to participate in any way in the Tampa Elite soccer Camp, related events and activities, the undersigned acknowledges, understands and agrees as follows: 1.I/We the parent/guardian listed above represent the camper listed above to the Tampa Elite Soccer Academy summer camp that the facts set forth in this agreement concerning the Camp Participant are true. 2. I/we am/are aware and familiar with the many ordinary and hazardous risks involved in sports including, but not limited to, travel to and from the site of activity, physical contact and the possible reckless conduct of other participants. I/we understand that the dangers and risks of participating in sports and related events and activities include but are not limited to, death, serious neck or spinal injury which may result in paralysis, brain damage, serious injury to all internal organs, injury to all bones, ligament, muscles, tendons, and other aspects of the body. I/we understand that the dangers and risks of participating in Tampa Elite Soccer Academy Camp may result not only in serious injury, but in serious impairment of future ability to earn a living, engage in business, and generally enjoy life. I/we understand on behalf of myself/ourselves and the Camp Participant, that I/we am/are assuming the risks. 3. I/we currently know of no physical or mental condition that would impair the Camp Participant’s capability for full participation in Tampa Elite Soccer Academy Camp as intended or expected [except for ______________________________________________ (please specify below)]. 4. I/we hereby give permission for the staff of the Tampa Elite Soccer Academy Camp to administer appropriate medical attention including, but not limited to, first aid, treatment and other services, to the Camp Participant in the event of accident, illness or injury occurring during the Tampa Soccer Camp. I/we understand that I/we will be responsible for any and all costs of medical attention and treatment provided to the Camp Participant. I/we aknowledge that the Camp Participant must have health and accident coverage in effect for the duration on the Tampa Soccer Camp. The name of the insurance company and policy number are provided below. 5. On behalf of myself/ourselves and the Camp Participant, Releasor(s) hereby release, waive, discharge and agree not to sue Tampa Elite Soccer Academy, The University of Tampa, and/or its officers, directors, servants, agents, employees, instructors, trip and event leaders, assistants and other representatives and, if applicable, the owners of leasees of premises in which sports and related events and activities are conducted (“Releasees”) FOR ANY LIABILITY, ACTION, CLAIM, LOSS, COST OR EXPENSE OF ANY KIND ARISING DIRECTLY OR INDIRECTLY FROM ANY AND ALL PERSONAL INJURY AND BODILY INJURY, DISABILITY, DEATH, OR LOSS OR DAMAGE TO PERSON OR TO REAL OR PERSONAL PROPERTY THAT MAY BE SUSTAINED BY THE CAMP PARTICIPANT WHILE INVOLVED IN SPORTS CAMP WHETHER ARISING FROM THE NEGLIGENCE OF THE RELEASEES OR OTHERWISE. 6. I/we further AGREE TO INDEMNIFY AND HOLD HARMLESS the RELEASEES from any loss, liability, damage or cost, including court costs and attorney’s fees, that they might incur due to the Camp Participant’s involvement or participation in the Tampa Elite Soccer Academy Camp and related events and activities WHETHER CAUSED BY NEGLIGENCE OF THE RELEASEES OR OTHERWISE. 7. I/we have read this release of liability and assumption or risk agreement, fully understand the terms, understand that I/we have given up substantial rights by signing it, and sign it freely and voluntary without any inducement. 8. I/we agree that this agreement is contractual in nature and will be governed by the laws of the state of Florida. In the event that any portion of this agreement is held invalid, I/we agree that the balance shall, not withstanding, continue in full legal force and effect. 9. I/we agree that this Agreement shall be legally binding upon myself/ourselves, my/our heirs, estates, assigns, personal representatives, executors, administrators and next of kin.
Please specify any current Physical or Mental limitations from Item #3:
Insurance Carrier:
Policy #:
Name of Family Physician:
Physician Phone:
By electronically signing my name below I acknowledge that I have read and understand the above liability release from and agree to its terms:
Parent/Guardian Signature:
Date:
I have read understand the Release, Consent, and Emergency Authorization Form.

TESA Inc.

3231 Marcellus Circle

Tampa, FL 33609

Adrian Bush - Director

Ph: 813-323-3933
Email: abush@ut.edu

Maurice Loregnard- Asst. Director

Ph: 813-495-2022
Email: mloregnard@ut.edu