Fillable Chesterfield Cheerleader League - Medical Form printable pdf download

CHESTERFIELD CHEERLEADER LEAGUE

MEDICAL FORM

YEAR: ________________

COMPLETION OF THIS FORM WILL COVER YOUR CHILD AT ALL CCL EVENTS FOR THE CURRENT YEAR

Name: _________________________________________________________________________________________________ Birth Date: ____________________ Grade in September: _____

Mailing Address: __________________________________________________________________________________City: ______________________________St: _____Zip:______________

Telephone #: (

) _______________________________ Emergency Contact: _________________________________________ Relationship: ________________________________________

Home Phone: (804) _______________________________ Business Phone: (

) ___________________________________________

If this person cannot be reached, please contact: ________________________________________________________________ Relationship: ________________________________________

Home Phone: (804) _________________ Business Phone: (

) __________________

Elementary School Boundary: _______________________________________________________

THIS FORM DOES NOT REQUIRE A PHYSICAL EXAMINATION

Please list all allergies: __________________________________________________________________Please list allergies to medication: _____________________________________________

Please list any medication which participant is currently taking: __________________________________________________________________________________________________________

Please make any necessary comments concerning physical condition, restrictions of participant, if any, etc.: _______________________________________________________________________

______________________________________________________________________________________________________________________________________________________________

INSURANCE INFORMATION: Please list name and address of insurance company that covers participant.

Name of Insurance Company: __________________________________________________________________________Policy #:____________________________________________________

Mailing Address: _________________________________________________________________________________City: ________________________________ St: _____ Zip: _____________

Name of Subscriber: _______________________________________________________________ Relationship to Participant: _______________________________________________________

_________ Please check this line if participant is NOT covered by an insurance policy. Please be aware that bills will be sent directly to parent or legal guardian.

MEDICAL TREATMENT / AUTHORITY STATEMENT

I, the undersigned parent/guardian, do hereby grant permission for my daughter/son/ward to attend cheerleading events sponsored and conducted by Chesterfield Cheerleader League. In order for

my daughter/son/ward to receive the necessary medical treatment in the event of an injury or illness, I hereby authorize Chesterfield Cheerleader League’s staff members to obtain medical treatment

for my daughter/son/ward for such injury or illness, I hereby hold Chesterfield Cheerleader League and their representatives harmless in the exercise of this authority.

I further acknowledge, understand and agree that in participating in these events there is a possibility of physical injury or illness that my daughter/son/ward is assuming the risk of injury or illness

by her/his participation. I assume full financial responsibility for such treatment.

WAIVER & RELEASE OF LIABILITY

In consideration of being allowed to participate in any way in the Chesterfield Cheerleaders League’s cheerleader sports program and related events and activities, the undersigned:

1. Agree that the parent(s) or legal guardian(s) will instruct the minor participant that prior to participating he or she should inspect the facilities and equipment to be used, and it the participant

believes anything unsafe, he or she should immediately advise his or her coach or supervisor of such condition(s) and refuse to participate.

2. Acknowledge and fully understand that each participant will be engaging in activities that involve risk and serious injury, including permanent disability and death, and severe social and severe

social economic losses which might result not only from their own actions, inactions or negligence but the actions, inactions or negligence of others, the rules of play, or the conditions of the

premises of any equipment used.

3. Assume all the foregoing risk and accept personal responsibility for the damages following such injury, permanent disability or death.

4. Release, waive, discharge and covenant not to sue Chesterfield Cheerleader League, its affiliated associations, their respective directors, agents, coaches, sponsors, and other employees of the

organization, other participants, sponsoring agencies, sponsors advertisers, and, if applicable, owners and leasers of premises used to conduct the event, all of which are hereinafter referred to as

“releases” , from any and all liability to each of the undersigned, his or her heirs and next of kin for any and all claims, property losses or damages on account of injury, including death or damage to

property, caused or alleged to be caused in whole or in part by the negligence of the releases otherwise.

I/WE HAVE READ THE ABOVE MEDICAL TREATMENT/AUTHORITY STATEMENT AND WAIVER & RELEASE OF LIABILITY, AND UNDERSTAND THAT I/WE GIVE UP

SUBSTANTIAL RIGHTS BY SIGNING IT AND SIGN IT VOLUNTARILY.

(X) Parent / Legal Guardian: _____________________________________________________________ Date: ______________________________

Printed name of Parent or Guardian: _______________________________________________ Printed name of participant: __________________________________________________________

Address of Participant: ___________________________________________________________________ City: _______________________________ St:______ Zip: _______________________

THIS FORM MUST BE SIGNED BY THE “X”. NO ONE CAN PARTICIPATE IN A CCL EVENT UNLESS THIS FORM HAS BEEN PROPERLY FILLED

OUT AND SIGNED BY A PARENT OR LEGAL GUARDIAN.