RELEASE AND MEDICAL WAIVER
CHILD’S NAME____________________________________= _____________________
AGE________ &nbs= p; DATE OF BIRTH___________________________________________
PARENT/GUARDIAN NAME ___________________________________________
PHONE NUMBER (HOME/CELL) __________________________________________
Does this child have any disabilities, handicaps, pres= ent injuries, or limitations, allergies, hemophilia, heart condition, history of respiratory illness or any other significant medical condition: YES NO If yes, please explain= in detail:
If you wish to have your family doctor contacted in ca= se of emergency:
Doctor’s Name:_______= ____________________ Phone:_________________________
EMERGENCY AUTHORIZATION: The undersigned parent or legal guardian of the participant, a minor, hereby authorize the coaches, assistant coaches or parents of team members acting = in the capacity of activity supervisors/vehicle drives, as my Agents, to conse= nt to medical, surgical or dental examination and/or treatment. In case of emergency, I hereby aut= horize treatment and /or care at any hospital.&nb= sp; If there is an emergency and I cannot be reached, please contact:
Name:______________________= ______ Phone: ___________________________= ____
Address:___________________= _____________________________________________
WAIVER OF LIA= BILITY AND DISCLAIMER- I,= the parent/guardian of the above name minor, acknowledge that participation in athletic events necessarily involves risk of physical injury. I further acknowledge= that the programs of Sanctuary Baptist Church League are primarily administered = by parents who volunteer their time rather than paid professionals. In consideration for accepting the registration of the above named minor and permitting the voluntary particip= ation of the said individual in its programs, I hereby release, discharge, and ho= ld harmless Sanctuary Baptist Church, its employees, volunteers, and other representative from any claims arising out of or relation to any physical injury that may result to said individual while participating in the Sanctu= ary Baptist Church League sponsored events, including any physical injury by the negligence of any official, referee or coach while performing his/her duties during any practices or games.
Signature of Parent/Guardian__________________________= ______ Date_________