Medical Release Form printable pdf download

Registration/Medical Release Form

Name: ____________________________________ Date of Birth: ________________

Address: __________________________________ Home Ph: ___________________

Address: __________________________________ Shirt Size: ___________________

Parent/Guardian

Name: ______________________ Work Ph: ________________ Cell Ph: ___________

E-mail address: __________________________________________________________

Emergency / Local Contacts if unable to reach parent:

Name: ____________________________________ Phone: ______________________

Physician: _________________________________ Phone: ______________________

Dentist: ___________________________________ Phone: ______________________

Insurance Company: ______________________________________________________

Policy/Group Number: _______________________ Phone: ____________________

Hospital: __________________________________ Phone: ______________________

In case emergency treatment is necessary, may the program supervisor use his/her judgment in

sending your child to a hospital or to the nearest physician before you are contacted?

Yes ________

No ________

In case you cannot be contacted immediately, may the physician/hospital contacted administer

any needed treatment? Yes ________

No ________

Are there any surgeries, physical handicaps, allergies or other conditions that the program

supervisor should be aware of? Yes ________

No ________

Please list allergy(s) and/or describe conditions, symptoms, medications, dosages, etc:

________________________________________________________________________

Assumption of Risk and Waiver of Liability

In consideration of the opportunity for our child, ____________________, to join the

2011 Clinton County Barracudas Swim Team, we the undersigned parent/guardian,

voluntarily assume, on behalf of our child, any risk of injury to him/her that may arise

during practices and meets of the summer swim season. These risks include, but are not

limited to, injuries due to racing dives, overexertion, competitive swimming or infection.

We also agree to waive any right of action against the Clinton Swim and Tennis Club, the

Miami Valley Swim Association, or the Clinton County Swim team, their officers,

volunteers, employees or independent contractors, arising out of any injuries that may

occur during our child’s swim team participation.

Parent/Guardian Signature: __________________________________ Date: __________

Age as of 6/1/2012: ____________

Male / Female (circle)

Fees paid: ______ (Initialed by Treasurer)

**Cost is $70.00 for dues paying members of the Clinton Swim and Tennis Club. If you

own stock and do not pay dues, then you are a non-member. Non members pay $130.00.

Membership Status: Member/ Non Member (circle) Checked by: ______ Date ______

Fees paid: _______ (Initialed by Treasurer)

Completed forms can be mailed or brought to the first practice. No swimmer will be

permitted in the pool until a completed form is received.

Medical Release Form

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