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Online Medical Release Form for Basketball 2019

* indicates a required answer.

1. *

Name of Player:

2. *

Birth Date: (MM/DD/YYYY)

3.*

Age as of September 1, 2019:

4. *

Street Address:

5. *

City:

6. *

Zip Code:

7.

Home Phone:

8.

Player's Cell Phone:

9.

Player's Email:

10.

Father's Name:

11.

Father's Employer:

12.

Father's Cell Phone:

13.

Father's Email:

14.

Mother's Name:

15.

Mother's Employer:

16.

Mother's Cell Phone:

17.

Mother's Email:

18. *

Medical Insurance Carrier:

19. *

Policy Number:

20. *

Medical condition and/or allergies that should be taken into consideration in the event medical treatment must be administered to your student (if none, then type NONE).

21. *

Person to contact, other than parent, in case of an emergency:

22.

Emergency Contact Home Phone:

23.

Emergency Contact Cell Phone:

24. *

In consideration of our student’s participation in the Christian Home School Athletics (CHSA) 2019-2020 Season:

We, the parents of the above named child, do hereby release, absolve and hold harmless the directors, coaches and leaders of CHSA Inc. from any and all liability for all losses, damages or injuries occurring as a result of our child’s participation in the activities of CHSA Inc., including travel to and from tournaments and other games within the Houston area or to other cities as required. We further agree to make or cause to be made, by assignment of third party benefits or otherwise, full and complete payment for examination, treatment or hospital care required in the case of a medical emergency.

 

We understand that reasonable precautions will be taken to make the program safe and beneficial for all children, but that risk of injury cannot be eliminated entirely, and that this release is necessary for our child to participate in the CHSA program. We also understand that athletic competition is strenuous by nature and acknowledge CHSA’s strong recommendation that our student obtain a complete physical examination before participating.

 

Furthermore, we hereby authorize, in the event our child suffers injury, any director, coach or leader of CHSA to consent to emergency medical treatment for our child when we cannot be contacted to so consent. Such medical treatment may include, without limitation, x-ray examination, anesthetic, medical, surgical examination or treatment and general hospital care. NO prior determination of life threatening emergency or danger of serious or permanent injury resulting from delay of treatment need be made under this authorization. This authorization is given in advance of any specific diagnosis, treatment, or hospital care being required, and is given to provide authority and power on the part of a director or coach of CHSA to give specific consent to any and all such examination, treatment, or hospital care.

 

We specifically give our consent for basic first aid treatment to be administered as necessary (e.g. bandages, antibiotic ointment, hydrogen peroxide, over-the-counter pain reliever, etc).

 

We hereby verify that we understand and accept the terms of this Medical Release and Authorization.

Type in your full name as your consent and signature as parent or legal guardian. 

25. *

Today's Date (MM/DD/YYYY):