Participant Application

Participant Name*

Email*

Phone*

Birth Date*

Age*

Sex*

Male
Female

Guardian 1 Name*

First Last

Guardian 1 Phone*

Guardian Email*

Guardian 2 Name

First Last

Guardian 2 Phone

Guardian 2 Email

Emergency Contact Name*

First Last

Emergency Contact Phone*

Physician Name

First Last

Physician Phone

Physician Email

Medical Insurance Carrier*

Coverage Number

Carrier Business Phone

Questionnaire

Please answer the following questions as they apply to your child or children. If more than one child will be participating in the E-Sports Program complete the information on each. If more space is needed pleas include an attachment. All information below is held strictly confidential, is not stored electronically, and is used solely for the purpose of child placement in the E-Sports Program.

Which E-Sports program will your child participate in?*

E-Soccer
E-Karate
E-Hoops
E-Football
E-Fitness
E-Dance

Select E-Sports Location(s) you will attend:*

Has your child participated in a group sports program before?*

Yes
No

If yes, please describe the type of program and length of play

Does your child have a “special need” or a medical diagnosis (e.g., allergies, asthma, hemophilia, heart condition, history of respiratory illness, or other significant medical condition, etc.) related to their ability to participate in a sports program that the E-Sports Program officials should be aware of?*

Yes
No

If yes, please explain in detail:

Please select any of the following conditions that may apply to your child:*

ADD/ADHD
High functioning Autism or Asperger's Syndrome or PDD/NOS
Moderate to Severe Autism
Down's Syndrome or other developmental disability
Cerebral Palsy
None of the above
Other

Please describe or list:

Please indicate the percentage of one-on-one instruction you feel your child will need to successfully participate in a group sports program:*

0--25% (Child can follow direction of coach with little to no individual assistance)
25--50% (Child is fairly independent in following instructions but may need some extra assistance. For example, has difficulty with transitions or needs help with balance at times)
50--75% (Child needs a coach directly assisting or monitoring them over half of the time)
75--100% (Child needs either a coach directly assisting or monitoring them almost all or all of the time)

Please check the top 3 most important goals for you child's participation in the E-Sports Program:*

Inclusion/social interaction
Balance and coordination
Strength and endurance
Gain skills for play in regulation competitive soccer games
Effort, determination, and perseverance
Empathy, acceptance, kindness
Selflessness
Leadership development/Train to become a junior coach
Other

Please describe:

EMERGENCY AUTHORIZATION: I, the undersigned parent or legal guardian of the participant, a minor, hereby authorize the person(s) leading or directing the E-Sports Program of the Bay Area Christian Church activities or events, including coaches, instructors, volunteers, the above identified emergency contact and/or other E-Sports Program officials, to use their best judgment and act as my agent(s) in obtaining medical, dental or surgical attention and/or treatment, for participant, should such attention or treatment become necessary and appropriate under the circumstances, as a result of the minor's participation in E-Sports Program activities or events. In granting this permission, it is expressly understood that any expenses incurred by or on behalf of the participant for such treatment and/or attention, are my sole responsibility and I represent and warrant that I have valid health care coverage and/or the financial ability to pay for such expenses. ASSUMPTION OF RISK: I, the undersigned parent or legal guardian of the participant, a minor, for myself and on behalf of the participant, our heirs, assigns and next of kin, acknowledge that participation in the E-Sports Program of the Bay Area Christian Church activities or events involves risk of physical injury or sickness from infectious disease and possible death. For myself, and on behalf of the participant, our heirs, assigns and next of kin, we willingly and voluntarily accept and assume all such risk. WAIVER, RELEASE AND INDEMNIFICATION: In consideration of E-Sports Program of the Bay Area Christian Church permitting the voluntary participation of the participant in its programs, I, the undersigned parent or legal guardian of the participant, a minor, for myself and on behalf of the participant, our heirs, assigns and next of kin, hereby waive all claims and release, discharge, agree to hold harmless and indemnify the E-Sports Program of the Bay Area Christian Church, its board of directors, officers, employees, volunteers, officials, sponsors and other representatives from any and all actions, claims, costs, expenses and demands of every kind and description including, but not limited to, personal injury, sickness, property damage and death, based on negligence, contract claim or other legal theory, arising out of, during or in any way related to the minor participating in E-Sports Program activities or events. PERSONAL INFORMATION - CONSENT, WAIVER AND RELEASE: I, the undersigned parent or legal guardian of the participant, a minor, for myself and on behalf of the participant, our heirs, assigns and next of kin, hereby consent and give permission to the E-Sports Program of the Bay Area Christian Church to take and compile sport related photographs, film, video and/or audio clips of the participant and to use them, along with my name and/or the name of the participant, as well as sport related personal information about myself and/or the participant, in any printed material, film, video, audio or other medium, including CD, Internet or other electronic media, describing, advertising or promoting the E-Sports Program. In consenting to such uses, we hereby waive the right to inspect and approve the images and information used, as well as all rights to compensation. We further release the E-Sports Program of the Bay Area Christian Church from any and all claims regarding use of the images or information, including, but not limited to, claims related to defamation, invasion of privacy, or infringement of moral rights, rights of publicity or copyright. I HAVE READ THE ABOVE EMERGENCY AUTHORIZATION, ASSUMPTION OF RISK, WAIVER, RELEASE AND INDEMNIFICATION AND PERSONAL INFORMATION -CONSENT, WAIVER AND RELEASE, AND I FULLY UNDERSTAND THE TERMS OF EACH. I FURTHER UNDERSTAND THAT THE PARTICIPANT AND I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY MY SIGNING THIS FORM AND AGREEING TO THESE TERMS. I AM AWARE THAT THIS FORM IS A LEGALLY BINDING AND ENFORECABLE AGREEMENT, AND I SIGN THIS FORM AND AGREE TO THESE TERMS FREELY AND VOLUNTARILY, WITHOUT INDUCEMENT FOR MYSELF, AND ON BEHALF OF THE PARTICIPANT.

I acknowledge that I have read the Authorization, Release and Consent form and accept the terms stated therein

Newsletter

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Participant Application

Thanks for your interest in E-Sports!

Please complete the following application in order for your child to participate at E-Sports.

Questionnaire