LIABILITY RELEASE WITH PARENTAL CONSENT
Medical Release and AuthorizationAs Parent and/or Guardian of the named athlete, I hereby authorize the diagnosis and treatment by a qualified and licensed medical professional, of the minor child, in the event of a medical emergency, which in the opinion of the attending medical professional, requires immediate attention to prevent further endangerment of the minor’s life, physical disfigurement, physical impairment, or other undue pain, suffering or discomfort, if delayed.Permission is hereby granted to the attending physician to proceed with any medical or minor surgical treatment, x-ray examination and immunizations for the named athlete. In the event of an emergency arising out of serious illness, the need for major surgery, or significant accidental injury, I understand that every attempt will be made by the attending physician to contact me in the most expeditious way possible. This authorization is granted only after a reasonable effort has been made to reach me.Permission is also granted to the Rodney Hoops LLC . and its affiliates including Directors, Coaches, and Team Parents to provide the needed emergency treatment prior to the child’s admission to the medical facility.Release authorized on the dates and/or duration of the registered season.This release is authorized and executed of my own free will, with the sole purpose of authorizing medical treatment under emergency circumstances, for the protection of life and limb of the named minor child, in my absence. Due to the 2019-2020 outbreak of the novel Coronavirus (COVID-19), our business istaking extra precautions with the care of every client to include health history review andenhanced sanitation/disinfecting procedures in compliance with CDC guidance.Symptoms of COVID-19 include:• Fever• Fatigue• Dry Cough• Difficulty BreathingI agree to the following:• I understand the above symptoms and affirm that I, as well as all householdmembers, do not currently have, nor have experienced the symptoms listed abovewithin the last 14 days.• I affirm that I, as well as all household members, have not been diagnosed withCOVID-19 within the past 30 days.• I affirm that I, as well as all household members, have not knowingly been exposedto anyone diagnosed with COVID-19 within the past 30 days.• I affirm that I, as well as all household members, have not traveled outside of thecountry or to any city considered to be a “hot spot” for COVID-19 infections withinthe past 30-days.• I understand that RODNEY HOOPS LLC cannot be held liable for any exposureto the COVID-19 virus caused by misinformation on this form or the health historyprovided by each client.Our business is following theses enhanced procedures to prevent the spread of COVID-19:• [list how your business is enhancing protection for clients amid COVID-19]By signing below, I agree to each statement above and release RODNEY HOOPS LLC from anyand all liability for unintentional exposure or harm due to COVID-19.
Child's Name
First Name
Last Name
Grade
5th Grade Boy
6th Grade Boy
7th Grade Boy
8th Grade Boy
9th Grade Boy
10th Grade Boy
11th Grade Boy
Parent's Name
First Name
Last Name
Phone Number
-
Area Code
Phone Number
Email
example@example.com
Signature
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Jersey Size
Youth Medium
Youth Large
Adult Small
Adult Medium
Adult Large
Short Size
Youth Large
Adult Small
Adult Medium
Adult Large
Number Request
Number Request #2
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Payment
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Registration fee :
$
20.00
New Players.
Returning Players
$
Free
For returning players only.
Quantity
1
2
3
4
5
6
7
8
9
10
Total
$
0.00
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