Player Medical Release Form &
Lockport Volleyball Camp
Player Medical Release Form &
Assumption of Risk Agreement
Both forms must be completed and signed by both the player and his/her parent or guardian, in each area indicated. Please know that this document will be kept in the possession of authorized, adult camp personnel and that care will be taken to insure the information contained herein is kept private and confidential. By signing these forms the participant affirms having read and agreed to all terms and conditions specified in this release.
Medical Release
______/ ______/ ______/ ______First Name / Last Name / Birth Date (mm/dd/yy) / Age
Primary Contact: Parent or Guardian
Name: / ______/ Street Address: / ______
Primary Phone: / ______/ City, State, Zip: / ______
Primary Email*: / ______/ Alternate Phone: / ______
*Your email address will be kept private and confidential and will not be released to any third party. Use of your email address will be limited to important camp related communication.
Secondary Contact: / / Parent/Guardian / / Other ______Name: / ______
Primary Phone: / ______/ Primary Email*: / ______
Primary Insurance Co: / ______/ Primary Group/Policy #: / ______/ ______
Family Physician Name: / ______/ Physician Phone: / ______
Please elaborate on any medical conditions of which we should be aware:
Any medications currently being taken:
Any allergies:
(If None, please write “None” after each)
Camper Signature: / ______/ Date: / ______
(regardless of age)
My child, ______, has my permission to participate in training, competition, events, activities, and travel sponsored by Lockport Volleyball Camp. I certify that my child/camper has full medical insurance with the company listed above. I understand and agree that this document will be kept in the possession of authorized adult camp personnel and that care will be taken to insure the information contained herein is kept private and confidential. I agree to allow authorized, adult camp personnel to release this information to a third party medical provider, in the event of a medical emergency. I also certify to the best of my knowledge that the camper named herein is physically fit to engage in the activities described above.
Parent/Guardian Signature: / ______/ Date: / ______Relationship to Participant: / ______
If, during the course of my daughter’s/son’s activities at Lockport Volleyball Camp, she/he should become ill or sustain an injury, I hereby authorize you to obtain emergency medical/dental care. I will assume financial responsibility for the bills incurred through my insurance company.
Parent/Guardian Signature: / ______/ Date: / ______
- or -
I do not authorize emergency medical/dental care for my daughter/son.Parent/Guardian Signature: / ______/ Date: / ______
(Continued on Reverse)
Informed Consent and Assumption of Risk Agreement
As a condition of being a participant in the Lockport Volleyball Camp, I acknowledge that I have read this form, fully understand it, and agree to its terms and conditions.
Initial
_____ 1. I hereby acknowledge that I have obtained medical clearance from my physician for participation in the Lockport Volleyball Camp. I further understand that I will be solely responsible for monitoring the manner and intensity of my involvement in camp, and will do so in a way, which will not jeopardize my health, safety or physical well being, or the health, safety or well being of other campers or staff. In particular, I agree that I am solely responsible for complying with my restrictions identified by my physician as to the participation in Lockport Volleyball Camp Activities. I further agree that if any circumstances occur which would impact my physician’s medical clearance, I will notify the Lockport Volleyball Camp Directors and Coaches immediately.
_____ 2. I agree to follow all directions of the Lockport Volleyball Camp Directors and Coaches and acknowledge that failure to follow such directions may result in the termination of my privilege and I will not continue to participate in the Lockport Volleyball Camp.
_____ 3. I hereby acknowledge that my participation in the Lockport Volleyball Camp involves risks of serious personal injury or death, including injuries to bones, muscles, tendons and ligaments, dehydration, abnormal blood pressure, fainting and heart disorders (including heart attacks), and any other personal injuries that may occur with strenuous physical activity. Based on the foregoing, I assume all risks associated with my participation in the Lockport Volleyball Camp.
_____ 4. I hereby release the Lockport Volleyball Camp Directors, Coaches and all workers associated with the Camp in their individual capacities for all claims (of any nature) relating to my participation in the Lockport Volleyball Camp, including, but not limited to, claims for personal injury or death and damage to or loss of personal items.
Camper’s Signature
Date
If camper is under the age of 18, the camper’s parent or guardian must also sign this form as acknowledgement and acceptance of the terms and conditions set forth herein on behalf of the camper.
Signature of camper’s Parent/Guardian
Date