Step 1 of 5 - Personal Information 20% All staff are required to read the R.E.A.L. Field Hockey staff manual before the first day. It will be emailed to you. All staff must complete required course and send certificate (pick one): CDC Heads-Up Course or NFHS Concussion Course. Any questions or concerns will be directed to the Director.* I agree and will email Director to receive staff manual and I will send certificate of head injury course completion Personal InformationName* First Last Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone*Email* Enter Email Confirm Email I will be available*All 3 DaysONLY on these dates (Specify below)I will be at attending ONLY these datesT-Shirt Size (Adult)*SmallMediumLargeX-LargeThird-Party Contact InformationEmergency Contact Name* First Last Emergency Contact Phone*Emergency Contact Relationship*Physician Name* First Last Physician Phone*Dentist Name* First Last Dentist Phone*References (Cannot be a parent)Reference #1 Name* First Last Reference #1 Phone*Reference #2 Name* First Last Reference #2 Phone*Reference #3 Name* First Last Reference #3 Phone* It is required by the State of Massachusetts Board of Health that each participant provide their most recent physical & immunizations dated within the past year. If you do not have these forms you will not be allowed to participate. Please send a copy.Physical Status*I have mailed/electronically attached an updated physicalPhysical is NOT current and will send a copy BEFORE first dayDate of current physical* Activity Restrictions (if yes please list below)*YesNoActivity RestrictionsCurrent Medications (if yes please list name and dosage below)*YesNoCurrent MedicationsMedical Conditions/History (if yes please list below)*YesNoMedical Conditions/HistoryAllergies (If yes please list below)*YesNo<AllergiesDrug Reactions (If yes please list below)*YesNoDrug Reactions Insurance InformationCarrier Name*Policy Holder* First Last Policy Holder Relationship To Staff*I, or my parent/guardian, give permission for me to receive emergency medical or surgical treatment and hospitalization if necessary. I understand that every attempt will be made to contact me or the named emergency contact before taking action. I hereby waive, release, indemnify and hold harmless R.E.A.L. Field Hockey, Inc., staff, camp management, agents and sponsors from any liability for any damages, accidents, injury or illness incurred while at camp. I UNDERSTAND THAT THERE IS A RISK OF INJURY TO ME AS A RESULT OF CAMP ACTIVITIES, AND KNOWINGLY AND VOLUNTARILY ASSUME ALL RISK OF SUCH INJURY. I will be financially responsible for any medical attention needed during camp. By signing below, I certify that all information on this form is accurate. * I Agree CORI RequestR.E.A.L Field Hockey, Inc. is requesting all available criminal offender record information (CORI) and juvenile data on the following individual from the Criminal History Systems Board pursuant to CHAPTER 6, §172G, which mandates operators of camps for children to request CORI and juvenile data regarding all employees or volunteers prior to employment or volunteer service.Name* First Middle Last Place of Birth*Date of Birth* Last 6 Digits of Social Security Number*Mother's Maiden Name*Current Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Former Address (if any) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAntigua and BarbudaArgentinaArmeniaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBosnia and HerzegovinaBotswanaBrazilBruneiBulgariaBurkina FasoBurundiCambodiaCameroonCanadaCape VerdeCayman IslandsCentral African RepublicChadChileChinaColombiaComorosCongo, Democratic Republic of theCongo, Republic of theCosta RicaCôte d'IvoireCroatiaCubaCuraçaoCyprusCzech RepublicDenmarkDjiboutiDominicaDominican RepublicEast TimorEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEthiopiaFaroe IslandsFijiFinlandFranceFrench PolynesiaGabonGambiaGeorgiaGermanyGhanaGreeceGreenlandGrenadaGuamGuatemalaGuineaGuinea-BissauGuyanaHaitiHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsraelItalyJamaicaJapanJordanKazakhstanKenyaKiribatiNorth KoreaSouth KoreaKosovoKuwaitKyrgyzstanLaosLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacedoniaMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMauritaniaMauritiusMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew ZealandNicaraguaNigerNigeriaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPolandPortugalPuerto RicoQatarRomaniaRussiaRwandaSaint Kitts and NevisSaint LuciaSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSpainSri LankaSudanSudan, SouthSurinameSwazilandSwedenSwitzerlandSyriaTaiwanTajikistanTanzaniaThailandTogoTongaTrinidad and TobagoTunisiaTurkeyTurkmenistanTuvaluUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVatican CityVenezuelaVietnamVirgin Islands, BritishVirgin Islands, U.S.YemenZambiaZimbabwe Country Gender*MaleFemaleOtherHeight (ft)*Height (in)*Weight (lbs)*Eye Color*State Driver's License Number OR Passport Number*CORI Photo*I have mailed/electronically sent a government photo required for CORI requestI have NOT sent a government photo and will do so immediately Photography ReleaseThis passage confirms the agreement between you and R.E.A.L. Field Hockey, Inc. regarding your participation in approved activities in which you may be photographed or videotaped from time to time. For valuable consideration received, you hereby irrevocably grant to R.E.A.L. Field Hockey, Inc. perpetually, exclusively, and for all media throughout the world (including print, nontheatrical, home video, CD-ROM, internet and any other electronic medium presently in existence or invented in the future), the right to use and incorporate (alone or together with other materials), in whole or in part, photographs or video footage taken of you as a result of your participation in approved activities of R.E.A.L. Field Hockey, Inc. You hereby agree that you will not bring or consent to others bringing claim or action against R.E.A.L. Field Hockey, Inc. on the grounds that anything contained in the Property, or in the advertising and publicity used in connection herewith, is defamatory, reflects adversely on you, violates any other right whatsoever, including, without limitation, rights of privacy and publicity. You hereby release R.E.A.L. Field Hockey, Inc., its directors, officers, successors and assigns from and against any and all claims, demands, actions, causes of actions, suits, costs, expenses, liabilities, and damages whatsoever that you may hereafter have against R.E.A.L. Field Hockey, Inc. This agreement shall not obligate R.E.A.L. Field Hockey, Inc. to use the Property or to use any of the rights granted hereunder, or to prepare, produce, exhibit, distribute or exploit the Property. R.E.A.L. Field Hockey, Inc. shall have the right to assign its rights hereunder, without your consent, in whole or in part, to any person, firm or corporation. I understand that these pictures will be accessible to anyone with Internet access and may be used in instructional settings, however, no names of subjects will be published.* I agree As part of the orientation, all counselors, junior counselors, and other staff and volunteers shall complete one on-line head injury safety training program, such as the Centers for Disease Control and Prevention’s “Heads-Up” training, or an equivalent training approved by the Camp Director. A proof of completion needs to be printed or emailed and provided before the first day of camp begins. Please contact vicky@realfieldhockey.com if you have any questionsAs part of the orientation, all counselors, junior counselors, and other staff and volunteers shall complete one on-line head injury safety training program, such as the Centers for Disease Control and Prevention’s “Heads-Up” training a href="https://www.cdc.gov/headsup/youthsports/training/index.html">https://www.cdc.gov/headsup/youthsports/training/index.html, or an equivalent training approved by the Camp Director. Please contact vicky@realfieldhockey.com if you have any questions Proof of completion*A proof of completion has been printed or emailedI will provide a copy before the first day begins
