Application will not be processed without completed consent form below. Full payment required for Day Program

Parental Consent Form
To enable the Health Center and/or other health facilities in the area to provide prompt care to your minor so, we must have a completed Parental Consent Form on file. This way, we can help your child without delay in the event of an emergency.

Name of Minor:   Birthday (M/D/Y):  


Medical Information 

Allergic Reactions:  

Medication Presently Taking:   Date of Last Tetanus Toxoid:  

Past illness or other information that would be useful in the event treatment is necessary. 
 

Emergency Phone Numbers
Father (Home):   Mother (Home):  

Father (Work):   Mother (Work):  
                

Please check One of the following permission options:
I grant permission to the director, assistants, or other persons responsible for his/her care to act on my behalf for said minor in granting permission for evaluation and treatment of medical problems. I understand that should a major medical problem arise, an attempt will be made to notify me by telephone. In the event that I cannot be reached, I hereby give my consent to such treatment as deemed necessary (including surgery, X-ray examinations and anesthesia to be rendered to said minor by a licensed physician or nurse). The participant agrees that soccer is a contact sport and Bob Winch's Charleston Soccer Training Centers at The Citadel and The Citadel will not be held responsible for any accidents, inury or loss, however caused and agrees to forever release and discharge the directors, agents, employees and any other person or corporation connected herewith from all manner of actions, injury, damages, costs, claims or demands which shall or may hereafter suffer or receive by reasons of participation in the program. Also, Charleston Soccer Training Centers at The Citadel reserves the right to use any pictures/videos taken during the program for advertising and instructional purposes.

I authorize limited care as follows:

I, , declare that I am the Choose One Father Mother Guardian of the above named minor.