Name *

First Name

Last Name

MEDICAL TREATMENT AUTHORIZATION AND LIABILITY WAIVER I hereby give my consent to have an athletic trainer, coach, team manager, emergency medical technician, nurse, medical treatment facility, and/or doctor of medicine or dentistry or associated personnel provide the applicant/participant with medical assistance and/or treatment and agree to be financially responsible for the cost of such assistance and/or treatment. I understand treatment for injury will be based on information provided herein. I hereby authorize emergency transportation of the applicant/participant to a medical treatment facility should an individual listed above consider it to be warranted. I recognize the possibility of physical injury associated with soccer, and hereby release, discharge, and otherwise indemnify the Telluride Soccer Academy, their sponsors, and its affiliated organizations, and the employees and associated personnel of these organizations, against any claim by or on behalf of the soccer player named above as a result of that player’s participation in Telluride Soccer Academy's Soccer programs and/or being transported to or from the same, which transportation I hereby authorize. *

I have signed and submitted the waiver via this site.

I will sign the waiver on-site.