CENTER GROVE ULTIMATE CLUB, INC.
Home
Events
Team Store
Ultimate Guides
HS Players' Guide
HS Parents' Guide
Sponsors
Alumni
Contact The Club
About
Ultimate Frisbee Basics
Seasons Overview
>
Coach Bio - Coach Noah
Coach Bio - Coach Katie
History
Club Org Chart
player medical authorization
The purpose of the Medical Authorization Form is to enable parents or guardians of players to authorize the provision of emergency treatment for their children who are injured or become ill while under the authority of the chaperone appointed by the Center Grove Ultimate Club, Inc. in the event the parents or guardians cannot be reached.
This release is effective for the time during which my child is participating in any Center Grove Ultimate scheduled events including but not limited to practices, conditioning, tournaments, games, scrimmages. This medical authorization is valid for a Club year (Aug. 1 - July 31).
section 1
*
Indicates required field
Player's Name
*
First
Last
Birth Date (mm/dd/yy)
*
Player's Allergies
*
Gender
*
Male
Female
Non-Binary
Emergency Contact Name
*
First
Last
[object Object]
Phone #
*
Relationship
*
Medications Player Currently Uses
*
Player's Medical History (major illness, hospitalization, surgery)
*
section 2
Parent or Guardian Name
*
First
Last
Primary Address
*
Line 1
Line 2
City
State
Zip Code
Country
Parent or Guardian Name
*
First
Last
Address (if different from primary address)
*
Line 1
Line 2
City
State
Zip Code
Country
Cell Phone #
*
Home Phone #
*
Work Phone #
*
Cell Phone #
*
Home Phone #
*
Work Phone #
*
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 acknowledges that we (I), the undersigned, parent(s) or legal guardian(s), 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 even of such an injury to my child and we (I or my spouse or guardian) cannot be contacted, we give permission to qualified and licensed EMTs, physicians, paramedics, certified athletic trainers, and/or other medical or hospital personnel to render such treatment.
We (I) hereby assume responsibility for any bills resulting from such treatment.
We (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. We (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.
Signature of Parent or Guardian
*
Date (mm/dd/yy)
*
Submit
Click
SUBMIT
before clicking
Back
or
Next
below.
Back
Next
Home
Events
Team Store
Ultimate Guides
HS Players' Guide
HS Parents' Guide
Sponsors
Alumni
Contact The Club
About
Ultimate Frisbee Basics
Seasons Overview
>
Coach Bio - Coach Noah
Coach Bio - Coach Katie
History
Club Org Chart