18+ Medical Authorization

CGUL player medical authorization

* Indicates required field

Player's Name *

First

Last

Birth Date (mm/dd/yy) *

Gender *

Male Female Non-Binary

Emergency Contact Name *

First

Last

Phone # *

Relationship *

Player's Allergies *

Medications Player Currently Uses *

Player's Medical History (major illness, hospitalization, surgery) *

HEALTH CARE PROVIDER & INSURANCE

Primary Care Physician *

First

Last

Physician's Phone # *

Health Insurance Company *

Group Plan *

Policy Number *

If Emergency Medical Care is Required Within Johnson County, Indiana, My Preferred Hospital is: Option 1 *

If Emergency Medical Care is Required Within Johnson County, Indiana, My Preferred Hospital is: Option 2 *

This Medical Authorization Form is effective for the time during which I am participating in any Center Grove Ultimate Club sponsored activities and valid for one Club year (Aug. 1 - July 31).

This Medical Authorization Form acknowledges that I, the undersigned, recognize the potentially hazardous nature of the sport of ULTIMATE and that an injury might be sustained. These injuries include but are not limited to PERMANENT DISABILITY, BLINDNESS, PARALYSIS AND DEATH. In the event of such an injury I give permission to qualified and licensed EMTs, physicians, paramedics, certified athletic trainers, and/or other medical or hospital personnel to render such treatment. I hereby assume responsibility for any bills resulting from such treatment.

I release Center Grove Ultimate Club, Inc. and USA Ultimate, its employees, its agents, its volunteers and its assigns from any personal injuries caused by or having any relation to this activity. I understand that this release applies to any present or future injuries or illnesses and that it binds my heirs, executors and administrators.

This release form is completed and signed by my own free will and with knowledge of its significance. I have read and understand all of its terms.

Player Signature *

Date (mm/dd/yy) *

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