PARENT CONSENT, WAIVER OR LIABILITY
AND MEDICAL RELEASE
Student’s name: _____________________________________________________
Date of birth: _______________________ School: _________________________
List all known allergies to medications: _______________________________________________
Date of last tetanus shot: ____________________ Current medications: ______________________
Medical Insurance Information:
Father’s Insurance Coverage Mother’s Insurance Coverage
Carrier: ___________________________ Carrier: __________________________
Policy: _____________ Group: ________ Policy: _____________ Group: ________
As the parent/guardian of the above named student, I hereby acknowledge that the risk of injury, including serious debilitating injury, is involved in athletic participation. I recognize that ISSA, PCISA and MBYC and their representatives make efforts to reduce these risks, but further recognize that their efforts cannot and will not eliminate all such risks. I am aware of the risks involved, and give my consent for the above named student to participate in all activities associated with the Baker elimination regatta.
I am aware that ISSA, PCISA, and MBYC do not carry medical insurance for students and that medical insurance coverage will be provided by parent/guardian. Evidence of such coverage is provided above.
I further release and hold harmless ISSA, PCISA, and MBYC, their Officers, Directors, Trustees, agents, employees, coaches and athletic trainers from any an all liability arising from the above-named student’s participation in the Baker elimination regatta and all related activities.
PERMISSION FOR MEDICAL CARE
I hereby grant permission to any appropriately qualified health care professional to give any and all medically appropriate emergency care to my son/daughter/ward, including but not limited to anesthesia and surgery.
_____________________________________ _________________________________________
Father/legal guardian date Mother/legal guardian date
_____________________________________ _________________________________________
address address
_____________________________________ _________________________________________
City State Zip City State Zip
_____________________________________ _________________________________________
home telephone cell telephone home telephone cell telephone