ML HARPER, LLC HIGH SCHOOL SOCCER CAMP WAIVER Medical Information Date of last tetanus immunization: _________________________________________________ Allergies to medicine? YES or NO. If YES, list: ______________________________________ Does the camper require medicine? _________________________________________________ List any significant illness or injuries that medical personnel should be aware of _____________ ______________________________________________________________________________ Emergency Contact Contact Name: _________________________ _Day Phone: _____________________________ Night Phone:____________________________ Cellular Phone:__________________________ Alternate Contact: _______________________ Phone: _________________________________ Health Insurance Company: _______________________________________________________ Policy Number: ________________________________________________________________ I hereby authorize any medical evaluation or treatment that may be prescribed by the attending medical personnel on behalf of ML Harper, LLC. Signed: _________________________ Camper’s Printed Name: _________________________ Address: ______________________________________ City: ___________________________ State: ____________ Zip Code: __________Phone: ___________________________________ High School: _____________________________________ Grade:_______________________ The following waiver and release is required by ML Harper, LLC (“Company”) for all campers: I (“Camper”), in consideration of my application for the Company’s High School Soccer Camp being accepted and other valuable consideration, the receipt and sufficiency of which is acknowledged – with the understanding that participation in such camp can expose me to certain risk – for myself, my heirs, executors, and administrators hereby waive, discharge, and release any and all rights and claims for damages that I may have against the Company, or its officers, agents, representatives, successors and/or assignees, for any and all losses, damages, or claims that may be sustained or suffered by me in connection with my association with the Company, including, without limitation, my participation in the Company’s High School Soccer Camp. I, being 18 or older, do hereby agree to the above waiver and release. Signed: __________________________________ I, the parent or guardian of Camper, for good and valuable consideration, the receipt and sufficiency of which is acknowledged, do hereby represent that I have the authority to sign on behalf of and bind Camper, my dependent, and agree to the above waiver and release on behalf of Camper. I further waive and release any claims I may have for damages, claims, or losses, including, without limitation, damages, claims, or losses for loss of the consortium of Camper. Signed: __________________________________, on behalf of Camper. Signed: __________________________________, parent or guardian on his or her own behalf.

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