MONTEREY PARK MUSTANGS

HOLD HARMLESS AND INDEMNIFICATION AGREEMENT, MEDICAL AUTHORIZATION, PERMISSION TO USE OF NAME AND LIKENESS FOR PUBLICITY & DISPLAY OF IMAGES ON THE MUSTANGS WEBSITE AND OTHER MEDIA

Player’s Name
(“Minor”): / Date of Birth:
Father’s Name: / Ethnicity:
Mother’s
Maiden name: / Home #:
Address: / Zip Code:
Email: / Cell #:
Sex: M/ F / Age: / Grade: / School:

Note: If the Minor is registering for the first time, a copy of the Minor’s birth certificate is required for submittal.

HOLD HARMLESS AND INDEMNIFICATION AGREEMENT

I/we, the undersigned parent, parents or legal guardian of the above named Minor, agree to hold harmless and indemnify The Monterey Park Mustangs, Gedatsu Church USA, its officers, coaches, managers, volunteers, and agents, hereinafter collectively and individually referred to as the“Mustangs”, from any injury incurred by the above named Minor by reason of basketball participation or any activity related thereto and from any loss resulting from any action, demand or claim brought by or on behalf oftheabove named Minor against the Mustangs as a result of said activities.

MEDICAL AUTHORIZATION

I/we, the undersigned parent, parents or legal guardian of the above named Minor, do hereby authorize The Monterey Park Mustangs as agent(s) for the undersigned to consent to any X-ray examination, anesthetic, medical or surgical diagnosis or treatment, and hospital care which is deemed advisable by, and is to be rendered under the general or special supervision of any physician or surgeon licensed under the provisions of the Medical Practice Act on the medical staff of any hospital, whether such diagnosis or treatment is rendered at the office of said physician or at said hospital.

It is understood that this authorization is given in advance of any specific diagnosis, treatment, or hospital care being required but is given to provide authority to power on the part of our aforesaid agent(s) to give specific consent to any and all such diagnosis, treatment, or hospital care, which a physician meeting the requirements of this authorization, may, in the exercise of his/her best judgment, deem advisable.

This authorization is given pursuant to the provisions of Section 25.8 of the Civil Code of California.

I/we hereby authorize any hospital which has provided treatment to the above named Minor pursuant to the provisions of Section 25.8 of the Civil Code of California to surrender physical custody of such Minor to ______(designated adult), and/or to the Emergency Contact person designated below, upon the completion of treatment. This authorization is given pursuant to Section 1283 of the Health and Safety Code of California.

I understand that any cost incurred for emergency medical, surgical, or dental treatment shall be my sole responsibility.

Doctor’s Name / Name of Hospital
Doctor’s Phone No. / Insurance Company Policy #

PERMISSION TO USE OF NAME AND LIKENESS FOR PUBLICITY & DISPLAY OF IMAGES ON THE MUSTANGS WEBSITE AND OTHER MEDIA

I/we, the undersigned parent, parents or legal guardian of the above named Minor, hereby grant the Monterey Park Mustangs, its agents and licensees, and other authorized media including television, radio and newspapers unrestricted permission to:

  1. Use and re-use the name, photograph, voice, likeness, and biographical information of the above named Minor, including the use of such information or likeness on television and in any other media for any purpose and for use in publicity and advertising in all media.
  2. Use, encode, digitize, copy, edit, excerpt, transmit and display the participation of the above named Minor on videotape, digital video stream, or any other media form;
  3. Use and re-use the name, voice, photograph, likeness, biographic information of the above named Minor in connection with the Monterey Park Mustangs website (

This permission shall apply to all activities in which the above named Minor participates as a member of The Monterey Park Mustangs including its extended or subsequent related activities.

I/we understand that the above information may/will be distributed to members of the public and media to: publicize the activities of The Monterey Park Mustangs as well as the performance of individual participants; promote The Monterey Park Mustangs as an organization in the community; and communicate information to participants and their families the success of The Monterey Park Mustangs.

This permission is irrevocable and royalty free and I understand that The Monterey Park Mustangs will act in reliance on this permission.

This Hold Harmless and Indemnification Agreement, Medical Authorization and Permission to Use Name and Likeness for Publicity is effective as to ______(name of Minor) from September 1, 2015 until August 31, 2016.

Date:______

Signature of Parent or Guardian

______

Print Name of Parent or Guardian

______

Emergency Contact #Emergency Contact Name

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