Team Hustle Dmv (Thd) Medical And Waiver Release For Spring Summer Season Form

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Team Hustle DMV (THD) Medical and Waiver release for Spring/Summer Season.
Player Name: _________________________________________Birthdate___/____/_____ Age: ____________
Address: ________________________________________________ City: _______________ Zip: ____________
Parent/Guardian Name if under 18): _____________________________________________________________
Home Phone: ________________________Work Phone: ________________________ Cell: ________________
Emergency Contact: __________________________ Phone: ______________ Relationship: _____________
Existing Medical Coverage: _________________________________________ Plan #:_____________________
Known Allergies: _____________________________________________________________________________
Current Medications: __________________________________________________________________________
I hereby voluntarily permit me or my child to participate in the Spring/Summer Season. I UNDERSTAND AND FULLY
ACCEPT THAT THERE ARE RISKS INVOLVED IN SPORTS, AND THAT ACCIDENTS AND INJURIES ARE COMMON AND ARE
ORDINARY OCCURRENCES OF SPORTS. I HEREBY AGREE TO ACCEPT ANY AND ALL RISKS OF INJURY OR DEATH, AND
VERYIFY THIS STATEMENT BY PLACING MY INITIALS HERE. _________ Initial Here
As consideration for being permitted by THD to participate in these activities, I hereby release and hold harmless Team
Hustle Organization, staff, volunteers, designated coaches, and program/tournament officials from all liability, and from
all actions or claims that I or my child now or hereafter have for damage or injury to me or my child, or to any person or
property, resulting from the negligence or other acts of any employees or volunteers in connection with me or my
child’s participation. I further agree that this waiver, release and assumption of risks is to be binding on the heirs and
assigns of the undersigned. I further agree to indemnify and to hold THD (its officers, employees, agents and volunteers)
free and harmless from any loss, liability, damage, cost or expense which they may incur as a result of any injury and/or
property damage that I or my child may cause or sustain while participating in this activity. In case of a medical
emergency, I hereby give permission to THD Staff, Trainers and Volunteers to order treatment for me or my child,
including any necessary medical treatment and x-rays. I also hereby give permission to TMH Staff and Volunteers to
disclose the information contained on this form to medical personnel. I understand that an attempt will be made to
reach me by phone when a diagnosis is completed. I agree to pay all medical, hospital, or other expenses which my child
or I may incur as a result of such treatment THD also does not provide any medical or other insurance protection or
benefits for those who participate in the Tyler Shaw Renn Memorial game.
I HAVE CAREFULLY READ THIS RELEASE AND FULLY UNDERSTAND ITS CONTENTS. I AM AWARE THAT THIS IS A RELEASE
OF LIABILITY AND A CONTRACT BETWEEN ME AND TEAM HUSTLE DMV AND SIGN IT OF MY OWN FREE WILL.
_____________________________________________________________ Date _______________________________
Parent or Guardian Signature

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