Release Of Liability / Medical Consent Form - New Mexico
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1RELEASE OF LIABILITY / MEDICAL CONSENT FORM/ REFUND POLICY FORM
(This form must be received prior to the camp in order for the camper to participate)
Camper’s Name ______________________________________
______________________________________
First
M.I.
Last
Camp Attending
Release of Liability, Medical and Surgical Authorization
In consideration of being permitted to participate in the Lobo Soccer Academy/University of New Mexico, I hereby assume the risks
of personal injury that may result from program activities. I am knowledgeable about the sport, have previously participated in the
sport, and am aware of the potential for injury while participating. As a participant and/or as a parent or guardian, I do hereby
release the University of New Mexico Board of Regents, the University of New Mexico, the Lobo Soccer Academy and their officers,
employees and agents, from all liability for personal injury or property damage which result from causes beyond the control of, and
without the fault or negligence of, the University of New Mexico, its employees, agents, or officers.
In addition, I hereby authorize and give my consent to the health authorities of Lobo Soccer Academy, the University of New Mexico
or any licensed health professional to perform upon or administer any reasonable, necessary surgical or medical treatment. I also
give permission to administer whatever anesthetic may be necessary or advisable during the medical or surgical procedures. This
authorization is intended to cover emergency treatment, immunizations, injections, and minor operations and procedures. In the case
of psychiatric and/or psychological treatment, parent authorization for treatment beyond that responsive to the emergency will be
requested. I agree to assume all costs related to such treatment. I authorize my insurance company to pay benefits to University of
New Mexico Health Service or other hospitals and clinics.
Also, I authorize the disclosure of medical information to my insurance company for purpose of claim. I understand that I will be
responsible for any medical or other charges in connection with student’s attendance at this camp. (Each camper must provide
his/her own medical insurance.)
Refund Policy:
If an accepted HIGH SCHOOL TEAM, ELITE OR JUNIOR ELITE application is withdrawn for any reason up until 15 days prior to the
start of the camp session you will receive a refund less a $75 cancellation fee. There will be NO refunds issued within 2 weeks of a
camp session's start date, unless the camper is withdrawing because of an injury that will not allow him/her to participate in the
camp. In this case a Doctor's note will be required to receive the refund less the $75 cancellation fee.
If an accepted HALF DAY OR FULL DAY DEVELOPMENTAL application is withdrawn for any reason prior to the start of camp, you will
receive a refund less a $30 cancellation fee.
No refunds will be issued following the start of a camp program unless serious injury prohibits camper from further participation.
Parent(s) or legal guardian(s) ________________________________________________________________________
Telephone Number: (Home, Work, Cell) ___________________________________
Emergency Contact Person __________________________________________________________________________
Telephone Number: (Home, Work, Cell) ___________________________________
Physician:_________________________________________________Telephone #_____________________________
Please provide the following information regarding Participant's health (ie: food allergies, medical allergies, medical conditions,
current medications):
__________________________________________________________________________________________________
__________________________________________________________________________________________________
______________________________________________
_____________________
Camper’s/Clinician’s Name or Signature (18 yrs. or older)
Date
______________________________________________
_____________________
Parents/Guardian’s Signature
Date
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