First Name:
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Last Name:
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Address:
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City:
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State:
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Zip:
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Area Code Telephone:
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Area Code Cell:
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Email:
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Birth Date:
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Name of Financial Guarantor
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First Name:
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Last Name:
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Area Code Telephone:
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Emergency Contact
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First Name:
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Last Name:
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Area Code Telephone:
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Area Code Cell:
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Location:
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You are completing the Consent Form for which SVSP service?:
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Other:
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I understand and agree to the following:
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| To make payment in full (or minimum of 1⁄2 total package price) on the first day of training. Annual program will be billed monthly. |
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| To use packages of 12 sessions within 12 weeks and packages of 24 sessions within 18 weeks (this does not apply to private training
packages). There will be NO make-up sessions or refunds unless approved by SVSP Management. |
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| To call within 24 hours if unable to attend scheduled training session. |
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| To attend one mandatory parent/guardian meeting during the first month of training. Time and date of meeting to be announced. (Applicable to those responsible for athletes participating in LTAD training phases only) |
Sports Performance:
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| I voluntarily agree to participate in the St. Vincent Sports Performance Program. The Sports Performance program has been fully explained to me and I have been given the opportunity to ask questions. I have been informed that if I have any questions regarding Sports Performance, the expected benefits, the risks or the alternatives to participation in Sports Performance, I may ask those questions before signing this consent form. |
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| I understand that all services will be provided by licensed health care professionals in accordance with the policies and procedures at St. Vincent Hospital and Health Care Center, Inc. I further understand that the confidentiality and privacy of such services shall be maintained in accordance with St. Vincent's notice of privacy practices. |
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| I agree to accept full responsibility for participation, my actions, and any injuries that may result from my voluntary participation in the program. I am without health issues or have disclosed any health issues which would preclude or increase any risk of injury from my participation in this program. I accept responsibility to abide by program rules of conduct and respect my assigned and reserved program timeframe. I release St. Vincent Hospital and Health Care Center, Inc., its employees, agents, affiliates, sponsors, and all program instructors from any and all liability in connection with my participation in the program. I acknowledge that no guarantees have been made to me as a result of my participation in the program. |
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Photograph/Autograph Prohibition:
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| I understand that I am an "At Will" participant and will respect the efforts of other participants. I understand the request for autographs or photographs of other participants is strictly prohibited. I also understand that any attempt to seek autographs or photographs from Sports Performance program participants is cause for expulsion from the program without a refund. |
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| I HAVE READ AND UNDERSTAND THE ABOVE-STATED INFORMATION. ST. VINCENT SPORTS PERFORMANCE IS NOT RESPONSIBLE FOR LOST OR STOLEN ITEMS. PLEASE LEAVE ALL VALUABLES AT HOME OR IN YOUR VEHICLE. |
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Name of Legal Guardian:
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Your Name:
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