Informed Consent Release Express Assumption Of Risk Form printable pdf download

INFORMED CONSENT RELEASE & EXPRESS ASSUMPTION OF RISK FORM

I realize that injuries can be a consequence of participating in this activity and no amount of reasonable supervision or

use of the facilities will prevent injury. I appreciate the character of the risk involved and I voluntarily assume on behalf

of my child all risk of possible harm or injury in participating in this designated activity (football).

I have carefully considered how the possible consequences of injury may impact my child’s life, and I choose to accept

this risk and allow my child to participate in the designated activity (football). In accepting this risk, I expressly and

explicitly release, discharge and waive any and all responsibility of Mansfield University of Pennsylvania’s State System

of Higher Education, the Commonwealth of Pennsylvania, and the employees, officials, or agents of any and all of the

foregoing, pursuant to, and pertaining or relating to, or arising from, in any matter, injuries to my child as a result of my

child’s participation in this activity football).

I give my permission to Mansfield University Public Relations Office to use my child’s photo/video image in various print

or broadcast media to promote Mansfield University. Media outlets may include, but are not limited to, print ads,

television ads, billboards, and movie theatre ads.

By my signature below, I certify that I completely understand this document. I certify that I am eighteen years of age or

older, and I am not under the influence of any drugs or alcohol.

_____________________________________

_____________________________

Signature of Parent or Guardian

Date

MEDICAL INFORMATION & AUTHORIZATION FORM

(All campers must provide proof of insurance coverage)

All campers must provide proof of insurance coverage that will cover any medical costs in the case of an injury.

Mansfield University and Mountie Football Camps do not assume financial responsibility for any medical expenses in the

case of an injury. No special physicals are necessary to attend the camp.

Insurance Coverage Information

Insurance Company: ___________________________________________________________________________

Policy #:_____________________________ Certificate # (if applicable): __________________________________

Pertinent Medical History

Date of last Tetanus Shot: _______________________________________________________________________

Any allergies or significant injuries: ________________________________________________________________

Prescribed Medications: ________________________________________________________________________

MEDICAL AUTHORIZATION STATEMENT

As a parent / guardian of ______________________________, I do hereby authorize any medical professionals’

permission to treat my son/daughter for an accident, injury, or illness.

In case of emergency, my work # is _________________________, my cell # is _________________________.

If I cannot be contacted, please contact the following, Contact name:_______________________________________

Phone#:_________________________ Relationship:_______________________

Signature: _______________________________________________________________________________

Informed Consent Release Express Assumption Of Risk Form