MS Medical Authorization

medical treatment authorization

The purpose of the Medical Authorization Form is to enable parents or guardians 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 for is valid during the 2020-2021 Club year (August 1, 2020 - July 31, 2021).

* Indicates required field

Player's Name *

First

Last

Date of Birth (mm/dd/yy) *

Gender *

Male Female Non-Binary

Allergies *

Medications Currently Used *

Medical History (major illness, hospitalization, surgery) *

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 # *

EMERGENCY CONTACT

Name *

First

Last

Relationship *

Phone Number *

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) *

Click SUBMIT before clicking Back or Next below.

Submit

Back