Preparticipation Physical Evaluation: Medical History Form (Page 3 of 5) in pdf

Assumption of Risk and Release of Liability

I ________________________, freely choose to participate in the athletic program (henceforth

referred to as the “Program”) at GateWay Community College. In consideration of my

participation in this program, I agree as follows:

RISKS INVOLVED IN PROGRAM: Participation in all sports requires an acceptance of risk of injury, such as

pre-season physical examinations, proper facilities maintenance, and instruction of correct sports technique, we

attempt to provide a safe, competitive environment for all student athletes. In addition we have team physicians,

(general practitioner and orthopedic specialist) and certified athletic trainers to assist you with injury prevention and

treatment.

In spite of these efforts, injuries do occur. Athletic competition, by its very nature results in numerous

uncontrollable situation where injuries cannot be avoided. As an athletic participant, there is always the possibility

that you may sustain an injury. The injury may range from a minor one to one of great severity and which could

result in deformity, paralysis, or even death.

HEALTH AND SAFETY: I have been advised to consult with a medical doctor with regard to my personal

medical needs. I state that there are no health-related reasons or problems that preclude or restrict my participation

in this Program. I have obtained the required immunizations, if any.

I recognize that GateWay Community College is not obligated to attend to any of my medical or medication needs,

and I assume all risk and responsibility therefore. In case of a medical emergency occurring during my participation

in this Program, I authorize in advance the representative of GateWay Community College to secure whatever

treatment is necessary, including the administration of an anesthetic and surgery. GateWay Community College

may (but is not obligated to) take any actions it considers to be warranted under the circumstances regarding my

health and safety. Such actions do not create a special relationship between the Maricopa County Community

College District (MCCCD) and me. I release the MCCCD, its officers, officials, employees, volunteers, students,

agents and assigns from all liability for any bodily injury or damage I sustain as a result of any medical care that I

receive resulting from my participation in Program, as well as any medical treatment decision or recommendation

made by an employee or agent of the MCCCD. I agree to pay all expenses relating thereto and release GateWay

Community College from any liability for any actions. I have been advised that I am covered under a secondary

athletic accident injury insurance policy for injuries sustained while participating in athletics at GateWay

Community College. I understand that any outstanding debts incurred as a result of medical treatment for that injury

is my sole responsibility.

ASSUMPTION OF RISK AND RELEASE OF LIABILITY: Knowing the risks described above, and in

voluntary consideration of being permitted to participate in the Program, I agree to release, indemnify, and defend

GateWay Community College and their officials, officers, employees, agents, volunteers, sponsors, and students

from and against any claim which I, the participant, my parents or legal guardian or any other person may have for

any loses, damages or injuries arising out of or in connection with my participation in this Program.

SIGNATURE: I indicate that by my signature below that I have read the terms and conditions of participation and

agree to abide by them. I have carefully read this Release Form and acknowledge that I understand it. No

representation, statements, or inducements, oral or written, apart from the foregoing written statement, have been

made. This Release Form shall be governed by the laws of the State of Arizona which shall be the forum for any

lawsuits filed under or incident to this Release Form of to the Program. If any portion of this Release Form is held

invalid, the rest of the document shall continue in full force and effect.

___________________________________

____________________

Signature of Student

Date

(and Parent/Guardian if under 18)

_________________________________________

Print or Type Full Name

Preparticipation Physical Evaluation: Medical History Form Page 3

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