Does this child have any disabilities, handicaps, present injuries or limitations, allergies, hemophilia, heart condition, history of respiratory illness, or any other significant medical condition? If yes, enter condition(s):

I, the parent/guardian of the participant hereby authorize the coaches or parents of team members acting in the capacity of activity supervisors to be my Agents, to consent to medical, surgical, or dental examination and/or treatment. In case of emergency, I hereby authorize treatment and/or care at any hospital.

By entering the date below, I the parent/guardian of the above-named individual, acknowledge that participation in athletic events necessarily involved risk of physical injury. I further acknowledge that the programs of Frazer Church are primarily administered by parents who volunteer their time rather than paid professionals. In consideration for accepting the registration of the above-named individual and permitting the voluntary participation of the said individual in its programs. I hereby authorize the Church to use, reproduce, distribute, display my child’s image, and photographs, as well as any video, digital, or audio recording or reproduction, in connection with external and internal communications of the Church for the sole purpose of advancing programs. I hereby release, discharge, and hold harmless Frazer Church, its employees, volunteers, and other representatives from any claims relating to any physical injury that may result to said individual while participating in the Frazer Church soccer league-sponsored events, including any physical injury from the negligence of any official, referee or coach while performing his/her duties during any practices or games.