Kinetic Volleyball Club

Kinetic Volleyball Club Registration Form

Athlete Medical Profile Form

Athlete Name*

Birthday (MM/DD/YYYY)*

AB Health Card Number*

Home Address*

City*

Postal Code*

Parent Name*

Contact Phone Number*

Contact Email*

Emergency Contact*

Emergency Contact Phone Number*

Please list any and all applicable health conditions:

List all prescription medications you currently take:

Known Allergies & Drug reactions:

List all non-prescription medications you currently take:

Physical Activity Waiver:

The applicant understands that risk is inherent in any physical activity and agrees that the Kinetic Volleyball Club (KV) and/or any individual connected with them will not be held responsible for any accidents or loss however caused. By registering for a session with the KVC camp, I accept personal responsibility for my participation in any activities and I agree to do so at my own risk. The KVC will not be responsible for any loss, damage, injury, or ambulance service in connection with such participation. I understand that every attempt will be made to contact the guardian or emergency contact should any emergency medical treatment or services be necessary. In the event that I or my alternative contact can not be reached, I give full consent for any licensed emergency service/medical personnel to provide treatment or service necessary to maintain the health of my child.

Photo and Video Consent:

Applicant agrees to permit the KVC to use your image (still and/or moving) for promotional purposes. By signing this document, you agree:

1. To allow the recording of your image (e.g. photographs or video).

2. To distribute your image and/or recording in any medium, be it print or electronic form, which may include the internet.

3. That there is no reimbursement for the right to take, or to use your photograph or video.

Print Parent's Name as Signature*

Date*

Camp Name

Parental Permission and Consent:

I agree that, in the event of illness or accident or emergency, I give my permission to my son/darughter's volleyball coach or representative of Kinetic Volleyball Club authorization to request medical treatment.

Physical Activity Waiver:

Option 1

Option 2

Option 3

Athlete Medical Profile Form

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