Activity Time Registration

Child's Name (Last/First/MI):
DOB (Month/Day/Year):
School:
Registering for which location(s):	Plumstead Peace Valley Campus Quakertown Christian School
Grade:
Parent(s) Name(s):
Address:
City, State, Zip:
Parent's E-mail:
Parent's Phone:
Insurance Company:
Policy #:
Emergency Contact:
Phone:
Physician:
Phone:

Allergies:
Medical History (Include anything we should know about your child):

I/We A value is required. the undersigned have legal custody of the child mentioned above and have given consent for him/her to participate in the Torch Premier Soccer activities. Please make a selection. I Agree WAIVER I/We A value is required. understand there are inherent risks in any activity, and I/we hereby release BuxMont Torch Sport Ministry and its staff from any liability for any injury, loss or damage to person or property that may occur during the course of my/our child's involvement. In the event he/she is injured and requires the attention of a physician, I/we consent to any reasonable treatment deemed necessary by a licensed physician. I/We acknowledge that we will be ultimately responsible for the cost of any medical care should the cost of that treatment not be covered by the health insurance provider. Further, I/we affirm that the health and insurance information that I/we have provided is accurate. I also agree to bring my/our child home at my/our expense should they become ill or if deemed necessary by the Torch Premier Soccer staff. Please make a selection. I Agree