Coach Khoa Registration Form & Waiver
Coach Khoa’s Los Paseos After School Program Registration Form 2019 - 2020
PRICE: (1 day a week = $65/month) (2 days a week = $90/month) (+$25/month per extra day) CASH or CHECK
*Sibling(s) discount available*, contact Coach Khoa: 408-579-9483 or firstname.lastname@example.org First payment is due before starting program. Continuing payments due on the first school day of every new month.
Payment days: 9/6/19 , 10/1/19 , 11/1/19 , 12/2/19 , 1/6/20 , 2/3/20 , 3/2/20 , 4/1/20 , and 5/1/20
First & Last name:_________________________________________________Gender: M or F Date of Birth:_____________ Full Address:___________________________________________________________________________________________ Parent(s) name:_________________________________________________________________________________________ Main Contacts Number(s):________________________________________________________________________________ Email:________________________________________________________________________________________________ Emergency Contact # if Parent/Guardian is not available__________________________________Relationship:____________
Allergies or other notes:__________________________________________________________________________________ Doctor’s Name/ Contact:___________________________Dentist Name /Contact:___________________________________ Insurance Carrier:_______________________________________________________________________________________ Group #:______________________________________Patient#:________________________________________
Parent/Guardian Consent for Participation & Photo, and Release of Liability
I/We, the undersigned, being the parent(s) or legal guardian(s) of________________________________, do hereby grant permission for his/her participation in Khoa Nguyen’s leagues/tournaments, and release Khoa Nguyen. and his agents from all causes of legal action, damages, and claims or inequity of any kind whatsoever from any illness injury or loss resulting from ___________________________’s participation in Khoa Nguyen’s sponsored sports, programs or activities. Said activities may include, but are not necessarily limited to the sports of soccer, street hockey, basketball, and program activities involving visual arts, music or the performing arts. I/We also hereby give consent and release, without recompense, for the use of photographs, recordings or videotape which may include _______________________________, taken for the purpose of Khoa Nguyen’s publicity, publications, promotions, or news media coverage of Khoa Nguyen’s activities. I/We also hereby agree that I/we and____________________________ will abide by the safe orderly and effective operation of Khoa Nguyen’s sports programs and activities, and understand that failure to so abide may result in termination of ____________________________________’s participation in Khoa Nguyen’s sponsored sports, programs or activities at the sole discretion of Khoa Nguyen.
Authorization to Consent to Treatment of Minor
In the event of injury in the course of participation in Khoa Nguyen’s sports, programs or activities, I/We, the undersigned being the parent(s) or legal guardian(s) of ___________________________ do hereby authorize Khoa Nguyen or his agents, acting as agents for the undersigned to consent to any triage, X-ray, examination, medication or anesthetic, medical or surgical diagnosis or treatment, emergency dental care, and related hospital care for ___________________________________ as may be deemed urgent and/or immediately advisable by, and is either rendered under the general or specific supervision of a physician, dentist or surgeon licensed under the provisions of the Medicine Practice Act or State of California-certified emergency first response personnel, whether such diagnosis is rendered at the office of said physicians, at a hospital, or in the field by licensed emergency first responder personnel. It is understood that this authorization is given in advance of any specific diagnosis, treatment or hospital care being provided, but is given to provide authority for Khoa Nguyen or his agent(s) to give specific consent to any and all urgent medical care which the aforementioned physician, dentist, surgeon or emergency first response personnel in the exercise of his/her/their best professional judgment may deem advisable at time of or following injury. This authorization is given pursuant to the provisions of Section 258 of the California Civil Code and shall remain in effect for as long as________________________________ participates in Khoa Nguyen’s sports programs or activities, unless revoked sooner in writing and personally delivered to Khoa Nguyen. It is also understood that failure to give or revocation of said authorization will necessarily result in the inability to participate and termination of participation from Khoa Nguyen’s sports programs and activities inasmuch as Khoa Nguyen will be effectively constrained from seeking prompt medical attention for the above named minor in the event of injury.
Signature of Parent/Guardian_______________________________________________Date:__________________________
Please print out and turn in to Coach Khoa with your payment.