Clone of Horizon Spiritline Pre-Tryout Clinic

Horizon Spiritline Pre-Tryout Clinic

Parental/Guardian Medical Waiver and Release Form
Participant Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Grade in School
Parents Name

First NameLast Name
Phone Number
Please enter a valid phone number.
Email
example@example.com

Medical Information
Any known allergies, illnesses, injuries, etc
Physician's Name

First NameLast Name
Physician's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Physician's Phone
Please enter a valid phone number.
Date of Last Tetanus Booster

MonthDayYear
Date
Insurance Information
Insurance Co. Name
Insurance Co. Phone
Please enter a valid phone number.
Policy Holder's Name
Policy Number / Group Number:

Emergency Information

If we can't reach you
Emergency Contact #1 Name

First NameLast Name
Emergency Contact #1 Phone Number
Please enter a valid phone number.
Emergency Contact #1 Relationship

Parental/Guardian Medical Release and Waiver
I hereby:
1. Give permission to the above-named participant to attend and participate in the Horizon High School (HHS) Spiritline Clinic.
2. Give permission to the staff to render first aid or emergency treatment if needed. If staff is unable to reach me, the treatment deemed necessary for my child’s health will be given.
3. Certify that the medical information given above is complete and accurate, and that no health-related situations preclude my child from participating safely.
4. Agree to assume all risk arising from my participation in clinic.
5. Agree to save, hold harmless, discharge and release HHS, their student instructors, coaches and parent volunteers for any and all liability, claims and causes of action, damages or demands in connection with participation in the clinic.
6. Understand that any medical expenses will be the sole responsibility of the participant’s parent or legal guardian.
7. Agree to accept any decisions made by the facilitating coach regarding a loss of participation by my child, if during the clinic, unacceptable or inappropriate behavior is exhibited by my child.
By signing below, I certify that I am the participant's parent or legal guardian and attest that I have read and agree to the above Parental/Guardian Medical Release and Waiver.
Typed Name of Parent/Guardian:
Signature of Parent/Guardian:

Clear
Date:

MonthDayYear
Date
Should be Empty: