Parent/Guardian Medical Authorization

OSSC

Parent/Guardian Medical Authorization

Release of Liability

Player:______Date of Birth: ______

In case of emergency, if family physician cannot be reached, I hereby authorize my child to be treated by Certified Emergence Personnel. (ie. EMT, First Responder, E.R. Physician)

Family Heath Care Provider: ______

Phone: ______

Insurance Carrier: ______

ID # ______

In case of emergency contact:

Name: Relationship: Cell phone #: Home #:
1. 
2. 
3. 

Please list any allergies/medical problems, including that requiring maintenance medication:

Diagnosis: Medication: Dosage: Frequency of dosage:
______

The purpose of the above listed information is to ensure that medical personnel have details of any medical problem which may interfere with or alter treatment.

Date of last Tetanus Toxoid Booster: ______

Printed name of parent/guardian:______

Signature of parent/guardian: ______

In consideration of being allowed to participate in OSSC programs, related events and activities, the parent/guardian signing this form acknowledges, appreciates and agree that. The risk of injury from the activities of these programs are significant, including the potential for permanent paralysis and death, and while particular rules, equipment and personal discipline may reduce the risk, the risk of serious injury does exist. I knowingly and freely assume all such risks, both known and unknown, even if arising from the negligence of the releases or others, and assume full responsibility for my participation; and, I willingly agree to comply with the stated and customary terms and conditions for participation. If, however, I observe and unusual or significant hazard during my child’s presence or participation, I will remove my child from participation and bring such to the attention of the nearest official immediately; and, I, for myself and my heirs, assigns, guardians, personal representatives and next of kin, hereby releases and hold harmless OSSC officers, officials, and other participants, sponsoring agencies, sponsors and advertisers (“Releases”), with respect to all and any injury, disability, death, or loss or damage to person or property, whether arising from the negligence of the releases or otherwise, to the fullest extent permitted by law. I HAVE READ THIS RELEASE OF LIABILITY AND ASSUMPTION OF RISK AGREEMENT, FULLY UNDERSTAND ITS TERMS, UNDERSTAND THAT I HAVE GIVEN UP SUBSTANTIAL RIGHTS BY SIGNING IT, AND SIGN IT FREELY AND VOLUNTARILY WITHOUT ANY INDUCEMENT By my signature I certify that I, as parent/legal guardian for the designated participant, do consent and agree to his/her release, as provided above, of all Releases, and, for myself, my heirs, assigns, and next of kin, I release and agree to identify and hold harmless the Releases from any and all liabilities incident to my minor child’s involvement or participation in these programs as provided above, even if arising from their negligence, to the fullest extent permitted by law.
______
Print name Signature Date