Faithfulness, Discipline, and Diligence, Inc.

AAU and YBOA Basketball

Medical Information & Consent Form

Athlete’s Name: ______

Address : ______

City: ______State: ______Zip: ______

Telephone: ______

Birthdate ______

Medical Information:

Doctor’s name: ______Doctor’s Phone:______

Health Insurance Carrier: ______Policy: ______

Any medical restrictions/problems? ______

Any allergies or medications being taken?______

Consent for Medical Treatment (Minor):

As the parent or legal guardian of the above named player, I hereby give my consent for emergency medical care prescribed by a duly licensed Doctor of Medicine or Doctor of Dentistry. This care may be given under whatever conditions are necessary to preserve the life, limb or well-being of my dependent. Please accept one of the parties named below as having received my permission to authorize medical treatment for my child in my absence:

Authorized Contacts for Medical Treatment:

1. ______Phone: ______

2. ______Phone: ______

I, the parent/guardian of the registrant, a minor, agree that I and the registrant will abide by the rules of the FDD AAU and YBOA Clubs, its affiliated organizations and sponsors. Recognizing the possibility of physical injury associated with basketball and in consideration for the AAU and YBOA accepting the registrant for its basketball programs and activities, I hereby release, discharge and/or otherwise indemnify the FDD AAU and YBOA Clubs, its affiliated organizations and sponsors, their employees and associated personnel, including the owners of the facilities utilized for the programs, against any claim by or on behalf of the registrant as a result of the registrant’s participation in the programs and or being transported to or from the same, which transportation I hereby authorize.

Name:______

Parent/Legal Guardian (Please Print)

Signature: ______Date: ______

I Hereby certify that on this ______day of ______, before me, an officer duly authorized in the State aforesaid and in the County aforesaid to take acknowledgements, personally appeared ______who is personally known to me or who has produced the identification identified below, who is the person described in and who executed the foregoing instrument, and who after being duly sworn says that the executed the foregoing instrument, and who after being duly sworn says that the execution hereof is his/her free act and deed for the uses and purposes herein mentioned.

SWORN TO AND SUBSCRIBED before me on the day and year last aforesaid.

_____ To Me personally Known

_____ Identified by Driver’s License Number ______

issued by the State of ______

______

Notary Public

Typed Name______

My Commission Expires______