Recognition and Assumption of Risk Agreement and Physician Release

I, the undersigned parent/legal guardian of _________________________, authorize said child's full participation in the Louisiana Soccer Academy, including related camp activities. It is my understanding that the participation in the activities that make up the Louisiana Soccer Academy, I hereby release, waive, discharge and covenant not to sue the camp program, the Southeastern Louisiana University Athletic Department, Southeastern Louisiana University, the officers, servants, agents, or employees from any and all liability, claims, demands, action and causes of action whatsoever arising outof or related to any loss, damage, or injury, including death, that may be sustained by my child, whether caused by the negligence of the releases, or otherwise while participating in such activity, or while in, or upon the premises where the activity is being conducted.

I also give my permission for any emergency medical care or treatment by a physician, surgeon, hospital, or medical care facility that may be required, including transportation, and accept responsibility for the cost. I also understand that a medical insurance policy carried by the Louisiana Soccer Academy, if any, will provide secondary coverage and that I should make sure my child is covered with family insurance in the event of a serious accident.

Print Camper's Name:
___________________________________________________________________________

Personal Insurance Company & Policy Number:
___________________________________________________________________________

Physician's Name & Number:
___________________________________________________________________________

Parent/Guardian Signature:
___________________________________________________________________________

I also agree to follow all instructions and procedures in order to maintain a maximum level of safety.

Camper's Signature:
__________________________________

This portion must be signed and returned with the camp application.