Soccer Winter ID Camp

Note: fields with an * must be filled out.

Washington State University Soccer Academy would like to invite you to attend its upcoming camp here on the WSU Campus. After making our fifth of the last six NCAA appearances, our program is competing with the best in the nation on a consistent basis.

These camps are great opportunities for our staff to see interested individuals on site. The camps are designed to develop tactical and technical skills that are essential to making it to the next level. Our experienced staff will run a typical collegiate training session, including possession exercises, passing patterns, and shooting drills.

The next ID camp will be our Winter ID Camp, January 27, 2018. This ID Camp will run from 9 a.m.-3 p.m., with lunch and a Cougar Soccer Academy T-shirt included. The cost of the camp is $110, and will be held on campus at Washington State University.

*First Name: Middle Name: *Last Name:

*Date of Birth (Month / Day / Year): Gender:

Position: Year of Graduation:

High School: Club Team:

*First Name: *Last Name:

*Relationship to Participant: *Email:

*Preferred Phone:( ) - Secondary Phone:( ) -

*Address: *City: *State: *Zip:

*First Name: *Last Name:

*Relationship to Participant:

*Preferred Phone:( ) - Secondary Phone:( ) -

First Name: Last Name:

Relationship to Participant:

Preferred Phone:( ) - Secondary Phone:( ) -

Has the camp participant had, or currently have, any of the following?

Concussions Heat Illness Surgery Current Orthopedic Injury
Sickle Cell / Trait Asthma Epilepsy Diabetes
Heart Condition (ie. HCM) ADD / ADHD Other No Previous or Current Medical Conditions

If you answered ‘yes’ to any of the above questions please explain below in the "General Health Information" section or submit additional information.

No known allergies.

This participant is allergic to:
 Food     Medicine     The environment (insect stings, hay fever, etc.)     Other
This participant has a life-threatening allergy.  An emergency care plan signed by physician is required.

Please describe below in the "General Health Information" section what the participant is allergic to, the reaction seen & any preventive or responsive measures utilized (ie. medications).

NOTE: It is strongly recommended that parents/legal guardians consult a physician prior to allowing their child to participate in physical activity.

Are there any medical concerns which the camp staff should be aware of? Submit additional information if needed.

Does the participant require reasonable accommodation for a disability in order to access or be part of the activities?

My child is up-to-date on his/her immunizations and tetanus shots as required by Washington State law.

My child has an immunization exemption on file with his/her school.  I understand and accept the risks to my child from not being fully immunized.

Unfortunately, we will be unable to administer medication to children participating in day camps.  If your child requires a dosage during camp hours, please make appropriate arrangements.  Medication is any substance a person takes to maintain and/or improve their health.  This includes vitamins & natural remedies. 

This participant will not take any daily medications while attending the activities.

Medication is any substance a person takes to maintain and/or improve their health.  This includes all prescription medication, as well as all over-the counter drugs that are potentially hazardous if misused (e.g., Tylenol, aspirin, cough medicine, cold tablets, vitamins & natural remedies.  All medications must be in their original containers.  Prescriptions must have the child’s name and how the medication should be given printed on the prescription container.  Please send only those medications that are necessary.  Participants are required to turn medications into staff upon arrival.

This participant will not take any daily medications while attending the activities.
This participant will be self-administering the following daily medication(s) while attending the activities under staff supervision.

Note: These provisions regarding administration of medication shall not abrogate minors' rights to provide their own consent to certain services under Washington law.

Name Of


Reason For

When It Is Given

Amount Or
Dose Given

How It Is Given



This health history is correct and accurately reflects the health status of the participant to whom it pertains. The person described has permission to participate in all program activities except as set forth by me and/or an examining physician. If you fail to advise WSU of a medical condition, risks to your child may increase. I understand the information on this form will be shared on a "need to know" basis with WSU staff and volunteers. I give permission to photocopy this form. In addition, the health care provider has permission to obtain a copy of my child's health record from providers who treat my child and these providers may talk with the program's staff about my child's health status.


Name of participant's primary doctor: Phone: ( ) -

Name of dentist: Phone: ( ) -

Name of orthodontist: Phone: ( ) -

Additional health care provider(s) name(s) and contact numbers:

*This participant is covered by family medical and/or hospital insurance: Yes     No

  Primary Insurance Secondary Insurance
Policy Number:
Insurance Company
Phone Number:
( ) - ( ) -


I understand that there are risks in participating in recreational activities and educational workshops at the Washington State University (WSU) Athletic Camp / Clinic.

In consideration for and as a condition of being allowed to participate in this voluntary activity, I agree to take full responsibility for any and all risks that exist, including the risk of death or injury to my child or loss or damage to my property.  I understand that there may be risks that WSU cannot predict or foresee, and I also assume full responsibility for those risks.

Risks in participating in WSU Camp activities, include, but are not limited to:  temporary or permanent muscle soreness, sprains, strains, cuts, abrasions, bruises, ligament and/or cartilage damage, orthopedic damage,  severe head, brain, neck or spinal injuries, paralysis, loss or use of arms and/or legs, eye damage, disfigurement,  or death.  I also recognize that there are both foreseeable and unforeseeable risks of injury or death that may occur as a result of traveling to or from WSU Camp activities that cannot be specifically listed.  Further, I recognize that the actions of other participants in the activity may cause harm or loss to my child or property.

In an emergency requiring medical attention or a situation reasonably believed by Washington State University (WSU) authorized agents including WSU Camp staff to be an emergency; I authorize WSU and its authorized agents to obtain emergency medical care for my child.  I will be responsible for any expenses incurred in so doing including but not limited to care by health care professionals, hospital care, and ambulance or other services. In addition, the health care provider has permission to obtain a copy of my child’s health record from providers who treat my child and these providers may talk with the program’s staff about my child’s health status.

I hold harmless and agree to indemnify Washington State University, its authorized agents and employees and the staff of WSU Soccer Camp from decisions to seek emergency treatment

I release, the state of Washington, the Regents of WSU, WSU, any subdivision or unit of WSU, its officers, employees, and agents, from any and all liability, claims, costs, expenses, injuries and/or losses to person or property, which I may sustain and/or sustain as a result of death or injury of my child, as a result of or connected with participation in the above event.  My child’s participation includes, but is not limited  to, travel to and from the event in a private or public vehicle, any activity connected with the event itself, and use of  state equipment or facilities for the event whether on or off WSU property.  I have carefully read this document, understand its contents and am fully informed about this program and circumstances. I am aware that this document is a contract with WSU and the program sponsors.  I enter this contrac freely and voluntarily.



Washington State University Athletics, PO Box 641602, Washington State University, Pullman WA 99164-1602, 509.335.0343, Contact Us