New Berlin Magic Health Card and Waiver Form

NEW BERLIN MAGIC HEALTH CARD AND WAIVER FORM

Team Name: ______Coach Name: ______

Participants Name: ______Age: ______Birthdate: ______

Address: ______City, Zip: ______

Father/Guardian: ______Mother/Guardian: ______

Work Phone: ______Work Phone: ______

Home Phone: ______Home Phone: ______

Cell Phone:______Cell Phone:______

Person to Contact in case Parent/Guardian cannot be

reached: ______

Cell Phone: ______Home Phone: ______

Health Insurance: ______Policy Number: ______

Present Medications: ______Allergies: ______

In case of serious accident or illness, and in case I cannot be reached, I authorize the head coach or his designee to provide appropriate emergency care. If an emergency transport is deemed necessary, I authorize the same to summon an ambulance to transport the participant to the hospital, or nearest facility based upon the condition pertaining to the incident. I also understand that if an immediate ambulance transport is deemed necessary, I may not be notified until after the transport has been initiated.

Parent/Guardian Signature: ______

WAIVER OF ALL CLAIMS AND INSURANCE VERIFICATIONS

The undersigned hereby waives and releases the New Berlin Magic from any and all claims, damages, costs, actions, and causes of action as the result of personal injuries sustained by the undersigned as the result of the undersigned’s participation in any and all competitive events, participating in the New Berlin Magic for the current year. In addition, the undersigned certifies that the participant is covered by a health insurance plan.

Player Name: ______Date: ______

Health Insurance Company: ______

Policy Number: ______Address: ______

Signature of Parent/Legal Guardian______