Maryville College
Medical Consent Form/Release of Liability
For Athletic Participation
This form must be completed before the camper will be permitted to participate.
Please Print:
Participant’s Name: ______Age ______
School Name: ______
Address: ______
City: ______State: ______Zip: ______
Parent’s/Guardian’s Phone: ______Cell: ______
Name of Insurance Company: ______
Policy Holder’s Name: ______
Plan Code Number: ______
Please note: Each camper must be covered by his or her own medical insurance.
1.) List known allergies or any chronic disease: ______
2.) If you are under a physician’s care, please list the name, address and phone number of the physician and what you are being treated for. Also list any medication you will be taking during your stay at camp:
______
______
PARENT’S AUTHORIZATION FOR MEDICAL TREATMENT AND RELEASE:
The undersigned, as parent or guardian of ______desires that my child participate in the above designated Maryville College camp and by execution of this release I agree that all requirements, directions and standards set by coaching staff and personnel shall be deemed to have been for the benefit of my child. In consideration of Maryville College’s efforts on my child’s behalf, I hereby voluntarily assume all risk of accident, injury, damage and/or loss to my child or child’s property which may arise out of my child’s participation in the designated Maryville College camp. I hereby release, relieve, indemnify and hold harmless Maryville College, its trustees, officers, employees and agents from and against any and all liability or causes of action for damage to property or injury to persons or any other liability or claim of any nature or description whatsoever arising out camp activities, except such liability or cause of action which arises out of the proven negligence on the part of the College, its trustees, officers, employees, or agents. I agree to cooperate fully with the College in any investigation of any incident occurring on College property or in the College’s facilities.
I/We authorize and request Maryville College, its nurse and/or athletic trainers to render first aid, treatment, medical or surgical care deemed necessary to the health and well being of my child. If necessary, I grant permission for hospitalization, treatment or surgery at Blount Memorial Hospital or other accredited facility. I further authorize athletic trainers at Maryville College who are under the direction and guidance of a physician to render any first aid or preventive, rehabilitative or emergency treatment deemed reasonably necessary to protect the health and well being of my child.
Date: ______
Parent/Guardian: ______
(Please print clearly) (Signature)
Parent/Guardian: ______
(Please print clearly) (Signature)