athlete Health & Safety Form Athlete Name * First Name Last Name Athlete Email * Emergency Contact * First Name Last Name Emergency Contact Email * Emergency Contact Phone * Country (###) ### #### Policy Number * Health Insurance Company * Group Number * Health Conditions Medications Assumption of Risk Statement * I understand and agree that the participation of my son/daughter in any camp or sports clinic held under Top Bins Soccer LLC is voluntary. I further understand and agree that Top Bins Soccer LLC is not liable for any injury, damage, or other loss which my son/daughter may cause or incur, or may cause others to incur while participating in any camp or clinic provided under Top Bins Soccer LLC. I have insurance coverage for my son/daughter, and specifically assume responsibility for all risks, injuries, damages, or other losses that my son/daughter might cause or incur while using any equipment and/or facilities at events run by Top Bins Soccer LLC, or while participating in any program, exercise or activity. I understand and agree to the statement above. Signature * Date * MM DD YYYY Thank you!
