Liability Release Form (Page 2 of 2) in pdf

I h ave r ead a nd v oluntarily s igned t his l iability r elease a nd a ssumption o f t he r isk a nd I a gree t o

accept a nd a bide b y t he t erms o f t his a greement.

I a gree t o a ccept a nd a bide b y t he r ules a nd r egulations o f J eff’s S ports C onnection.

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Signature o f P arent o r G uardian

Date

In c ase o f e mergency a nd i f u nable t o c ontact a p arent o r g uardian, p lease n otify:

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(Name, a ddress, p hone n umber(s))

CONSENT T O T REAT M INOR

In t he e vent o f s udden i llness, a ccident o r i njury w hich m ay o ccur w hile s aid m inor i s e ngaged i n

an a ctivity s upervised b y J eff’s S ports C onnection, J effrey R . P owell, t he C ity o f A naheim, t he

American S ports C enter, t he C ity o f O range, t he S uper S ports C enter, t he T ustin S alvation A rmy,

the C ity o f T ustin, O range H igh S chool a nd O range U nified S chool D istrict, a nd a ny i nvolved

municipalities o r o ther p ublic e ntities, t heir e mployees, r epresentatives, a gents o r a ssignees,

when n either p arents, g uardian, o r d esignated f amily p hysician c an b e c ontacted, I h ereby

authorize e mergency t reatment p ursuant t o C alifornia C ivil C ode # 25.8 a s s hall b e n ecessary

under t he c ircumstances t o b e r endered b y p hysician o r d entist l icensed u nder t he l aws o f t he

State o f C alifornia.

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Signature o f P arent o r G uardian

Date

Family P hysician: _ ________________________ Phone: _ ________________________

Insurance C o.: _ __________________________

Type o f c overage: _ ________________

Pertinent m edical h istory i nformation ( epilepsy, d iabetes, a llergies, e tc.):

_ _________________________________________________________________________

Liability Release Form Page 2