Wentworth's Mens Soccer October Prospect Clinic

Thank you for your interest in Wentworth Athletics. This clinic is brought to you by the Wentworth Men's Soccer coaching staff and players.

Complete this form to register for the event. Please note that a parent or guardian must be present to complete the registration.
Fields marked with an * are required.
All Skills Prospect Clinic 9:00 AM - 3:00 PM (Sign-in 8:30 -8:45 AM)

Participant Information

First Name (Given Name) *

Preferred Name (if different from First Name)

Last Name (Family Name or Surname) *

Personal Email Address *

Please confirm your email address

Birthdate*

What term are you planning to start college?*
(For students graduating high school in the spring, this is typically fall of the same year.)

Athletics Clinic Information

Primary Postion

Secondary Position

Club Soccer Team

Academic Information

Current or most recent High School attended
(begin by typing the first few letters of the name of your high school)

When will you graduate from high school (or receive your GED)?

Contact Information

Mobile Phone Number
(We may text you with important event reminders unless you opt-out below.)

Check here to OPT OUT of occasional event and deadline reminders via text.

Home Phone Number (if different from mobile)

Mailing Address

Country

Street

City

Region

Postal Code

Check here if your permanent address is different from your mailing address.

Permanent Address *

Country

Street

City

Region

Postal Code

Parent Information

Parent/Guardian First Name*

Parent/Guardian Last Name*

Parent Email Address*

Parent/Guardian Mobile Number*

Emergency Contact Information

Your emergency contact must be different than the individual listed above in the parent/guardian section.

Emergency Contact First Name*

Emergency Contact Last Name*

Emergency Contact Mobile Number*

Liability Waiver

All registrants for the Athletics Clinic must sign off on the attached Liability Waiver form.

In addition to Participant’s signature, where appropriate, Participant’s parent(s)/guardian(s) must sign any documents as well, prior to submission.

If you have any questions about any of the documents in this package before or after signing these forms, you can contact the Pre-college Programs Office (precollege@wit.edu, 617-989-4000).

PARTICIPATION AGREEMENT

General Participation:

I understand that I will be participating in Wentworth's Mens Soccer October Prospect Clinic taking place on campus from 8:30 a.m. until 3:00 p.m.

General Consent:

I represent that I am at least 18 years of age, have read and understand the foregoing statement and am competent to execute this agreement. I understand that if I am less than 18 years of age, it is required that my parent or legal guardian sign the document in addition to my signature.

PROGRAM REGULATIONS

Attendance & Participation. Participants are expected to attend all Program activities. They are expected to be punctual and to participate in a respectful manner. If for any reason the Participant is unable to attend or arrive on time to any activity, the Participant must contact the Director in advance. If a Participant is absent and unaccounted for, we will contact the Participant using the contact information provided. If we are unable to reach the Participant after 30 minutes, we will contact the Participant’s parent or guardian according to the contact information provided. Participants who is absent or unaccounted for may be withdrawn from the program at Wentworth's discretion.

Behavior. Participants must abide by all applicable federal, state, local laws, and Wentworth rules, regulations, policies, codes (including the student code of conduct https://www.wit.edu/student-life/community-standards) and procedures as well as all Program Rules and Regulations (collectively “Wentworth policies”). Any Participant who endangers his or her own health or safety or the health or safety of another participant, student, staff member, or faculty member will be subject to removal from the program. The procedures in the Student Handbook for processing violations of the Student Code of Conduct do not apply to Athletics Clinic Participants. Decisions on Participant conduct rests in the sole authority of the Program Director.

Consumption, possession, or being in the presence of alcohol, marijuana or illegal drugs is grounds for immediate dismissal, as is possession or use of drug paraphernalia, firearms, knives, other weapons, or fireworks. In addition, Wentworth is a Tobacco Free campus and use of tobacco products of any kind, including e-cigarettes and personal vaporizers is strictly prohibited. Marijuana in any form, whether it is for medical, recreational, or other purposes, is not allowed on campus.

Participants must not engage in any form of harassment, hazing, intimidation or bullying. Bullying means any behavior, whether in-person, groups, or through other mediums (hand written notes, phone calls, social media, texting, etc.), intended to, or which cause fear, intimidation, abuse or damage to property of another Participant, student, staff or community member.

Participants must show respect for the rights and safety of others in the community including Wentworth’s neighbors. Disturbances, public intoxication or other such behaviors will not be tolerated.

Any violation of Wentworth policies, or the behavior policies contained in this section could result in dismissal from the Program and if applicable, withdrawal of Participant’s acceptance to Wentworth Institute of Technology. If dismissal from the Program is deemed necessary, the Participant will be sent home at the expense of his or her parents or legal guardian(s).

Financial Responsibility. The parents or legal guardians of Participants in the Program are financially responsible for any damage or loss suffered by Wentworth caused by their son, daughter, or ward.

Medication. It is the Participant’s responsibility to secure and self-administer any necessary medications.

Disciplinary Sanction

Failure to abide by Wentworth policies, the Program rules and regulations, federal state and local laws, or failure to respect the authority of Program staff members, faculty and other Wentworth personnel (including Public Safety) in their enforcement, may result in sanctions including, but not limited to:

Parental or Guardian Contact
Limitations on activities
Restitution for property damage
Dismissal from the Program. If dismissal is deemed necessary, the Participant will be sent home at the expense of his or her parent(s) or legal guardian(s). No refunds will be issued.
If applicable, Withdrawal of Acceptance to Wentworth Institute of Technology

Our signatures below indicate that, having had an opportunity to read and review Wentworth policies and Program rules and regulations (Participant) and (Parent/Guardian), we agree to support and abide by all Wentworth policies and Program rules and regulations policies, and federal, state and local laws and to encourage the spirit they mean to foster. We understand failure to sign and return the Participation Agreement will prohibit Participant from participating in the Program.

By clicking the “accept terms ”, I affix my electronic signature and consent to this Agreement. I understand and agree that I am signing this agreement electronically and my electronic signature is the legal equivalent of my manual signature under Massachusetts state law. I understand and agree that the electronic signature on this agreement is the same as my handwritten signature for purposes of validity, enforceability, and admissibility.

I accept

Signature of Participant

Date of Birth of Participant

Signature of Parent/Guardian

USE OF PHOTOGRAPHIC LIKENESS RELEASE FORM

THIS IS A RELEASE OF YOUR RIGHTS. READ CAREFULLY BEFORE SIGNING.

For good and valuable consideration, I, Participant/Participant Parent/Guardian , authorize the Wentworth Institute of Technology (“Institute”) and its agents to record photographs or other portraits or likenesses of Participant on videotape, audiotape, film, photograph or any other medium and to use, reproduce, modify, distribute, and publicly exhibit such recordings, in whole or in part, without restrictions or limitation for marketing or any other purpose that the Institute deems appropriate. I further consent to the use of my name, voice and biographical material in connection with such recordings.

I release the Institute, its Trustees, officers, employees and agents from any liability whatsoever based on or related to its use of any photographs, portraits, or other likenesses of me in any medium and the use of my name, voice, or biographical information, including without limitation violation of rights of privacy, publicity, libel, defamation or any similar right, for the purposes described above. I further release the Institute, its Trustees, officers, employees and agents from any liability by virtue of any blurring, distortion, alteration, optical illusion, or use in composite form, whether intentional or otherwise, that may occur or be produced in the recording process, or any unintentional misspellings or inaccuracies. I waive any right I may have to inspect or approve any finished photographs, portraits, or other likenesses of me.

By clicking the “accept terms ”, I affix my electronic signature and consent to this Agreement. I understand and agree that I am signing this agreement electronically and my electronic signature is the legal equivalent of my manual signature under Massachusetts state law. I understand and agree that the electronic signature on this agreement is the same as my handwritten signature for purposes of validity, enforceability, and admissibility.

I accept

Signature of Participant

Date of Birth of Participant

Signature of Parent/Guardian

ACCIDENT WAIVER AND LIABILITY RELEASE

THIS IS A LEGAL DOCUMENT REQUIRING YOU TO GIVE UP YOUR LEGAL RIGHTS.

This is a legally binding Release made by me, Participant and Parent/guardian (collectively “Participant” or “Releasor”) to Wentworth Institute of Technology, all of its current and former trustees, officers, directors, faculty, staff, contractors, students and agents (collectively the “Institute”).

I fully recognize that there are dangers and risks to which I may be exposed by participating in the Wentworth's Mens Soccer October Prospect Clinic at Wentworth Institute of Technology (“Program”).

Description of Program Activities (“Activities”)

I understand and acknowledge that my participation may consist of attending session(s) offered as part of the Program by the Institute. Such sessions may include intensive athletic drills, competitive scrimmages, and review of athletic films.

I will be solely responsible for transportation to and from the Program. Parking of personal vehicles on campus during the program is only permitted if approved beforehand by the Wentworth Public Safety Department as may be coordinated by the Program.

Release

I, Releasor, understand that the Institute does not require me to participate in this activity, but I choose to do so, despite the possible dangers and risks and despite this RELEASE. I, Releasor, therefore agree, in consideration of and return for the services, facilities, and other assistance provided to me by the Institute in this Program, to the fullest extent permitted by law I do RELEASE the Institute from any and all liability, claims and actions that may arise from injury,harm to, or death of Participant, or from the loss or damage to Participant’s property in connection with participation in this Activity. I understand that this RELEASE covers liability, claims and actions caused entirely or in part by any acts or failures to act of the Institute (or its Trustees, employees, or agents), including but not limited to negligence, mistake, or failure to supervise by the Institute.

I fully understand the scope of the activities and the risks involved. I voluntarily accept and assume all risks of injury, loss of life, or damage to property arising out of Participant’s participation in the Program.

I recognize that this RELEASE means I am giving up, among other things, rights to sue the Institute, its Trustees, employees, and agents for injuries, damages, or losses I may incur. I also understand that this Release binds Participant, their heirs, executors, administrators, and assigns, as well as myself.

By clicking the “accept terms ”, I affix my electronic signature and consent to this Agreement. I understand and agree that I am signing this agreement electronically and my electronic signature is the legal equivalent of my manual signature under Massachusetts state law. I understand and agree that the electronic signature on this agreement is the same as my handwritten signature for purposes of validity, enforceability, and admissibility.

I accept

Signature of Participant

Date of Birth of Participant

Signature of Parent/Guardian

MEDICAL CONSENT FORM

(To be completed by parent/guardian if Participant under age 18)

In submitting this form, I hereby certify that, to the best of my knowledge, the medical information furnished herein is true and complete.

In case of medical emergency, I hereby give the Wentworth Institute of Technology permission, on Participant’s behalf to secure proper treatment for, transport to a medical facility and to order injection or minor surgery for Participant.

I agree to assume financial responsibility for all expenses of such care. It is understood that this authorization is given in advance of any such medical treatment but is given to provide authority and power on the part of the Wentworth in the exercise of its best judgment upon the advice of any such medical or emergency personnel.

Doctor’s/Medical Care Provider’s Information and Health Insurance

Health Provider's Name

Health Provider's Phone Number

I hereby certify that Participant is covered by health and accident insurance or Medicaid. The policy information is:

Policy Number

Coverage Provider

Policy Holder's Name

By clicking the “accept terms ”, I affix my electronic signature and consent to this Agreement. I understand and agree that I am signing this agreement electronically and my electronic signature is the legal equivalent of my manual signature under Massachusetts state law. I understand and agree that the electronic signature on this agreement is the same as my handwritten signature for purposes of validity, enforceability, and admissibility.

I accept.

Signature of Participant

Date of Birth of Participant

Signature of Parent/Guardian

Pay For Athletics Clinic

Amount Due
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Amount Due

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Men's Soccer Clinic Fee