Parent/gaurdian permission and emergency
treatment form
Child’s Name: _____________________________________________________
Age: _________________
Address:
________________________________________________________________________________
City:
Is he/she in Good physical
condition with no serious illness or operation since his/her last exam?
__________ Yes __________ No
Is he/she currently taking
any medication, including prescription and over-the counter?
__________ Yes __________ No
Does he/she have any chronic
or ongoing medical conditions (such as: allergies-food and other, diabetes, ear
infections, contact lenses, etc.) of which the staff should be aware?
__________ Yes __________ No
If “Yes” please specify and
give specific reactions of an allergy situation:
Physician’s Name: ______________________________________
Phone#: __________________________
Medical Insurance Coverage:
_____________________________ Policy#: ___________________________
EMERGENCY DATA: Name(s) and telephone
number(s) at which parent(s) and guardian(s) can be reached during the time the
child will be attending the Home School Basketball Program.
_____________________________________________
__________________ ____________________
Mother’s Name (Guardian) Home
Phone Other Phone
_____________________________________________
__________________ _____________________
Father’s Name (Guardian) Home Phone Work/Other Phone
If Parent/Guardian cannot be
reached please contact: ___________________________________________
PLEASE READ THE FOLLOWING
CAREFULLY AND SIGN ONE OF THE
TWO BELOW:
1.)
In the event that
I cannot be reached in an EMERGENCY, I hereby give permission to the physician
selected by the person in charge to secure emergency treatment for my child as
named above:
Parent/Guardian Signature:
______________________________________________ Date: ______________
2.)
In the event that
I cannot be reached in an EMERGENCY, I DO NOT give permission to secure
emergency treatment for my child as named above. Instead I request that the
person in charge do the following:
Parent/Guardian Signature:
______________________________________________ Date: ______________
RELEASE FOR PERSONAL INJURY
Releasor voluntarily and
knowingly executes this release with the intention of eliminating Brad Vaughn
from liabilities and obligations as described below.
Releasor hereby releases Brad
Vaughn from all liability for claims, known and unknown, arising from injuries;
mental and physical, sustained while participating in the Home School
Basketball Program.
In executing this release
Releasor additionally intends to bind his or her spouse, heirs, legal
representatives, assigns anyone else under claiming him or her. This release
applies to Brad Vaughn’s heirs, legal representatives, insurers and successors,
as well as to Brad Vaughn.
Releasor’s
Signature: ________________________________________________________ Date:
___________________