Temporary Power Of Attorney And Medical And Liability Release Form printable pdf download

TEMPORARY POWER OF ATTORNEY

AND MEDICAL AND LIABILITY RELEASE FORM

This form covers all events and/or activities sponsored by CHIEF Basketball, valid from:

November 1, 2015 to March 31, 2016

One form to be completed for each player

Player's Name: ________________________________________

Parent or Guardian: _______________________________________________________________

Address: _________________________________________________________________________

Street ________________________ City ____________________

State _____ Zip _________

Doctor ________________________________ City _____________________ Phone ( ____ ) ___________

Health Insurance Co: __________________________________ Policy #: ____________________________

In the case of an emergency, parent/guardian is to be notified in the order specified on the player registration

form. If I or the doctor cannot be contacted, notify _________________________ Phone ( ____ ) _________

Address: ________________________________________________________________________________

Street

City

State

Zip

HEALTH HISTORY

❑ Food Allergies? _______________________________

❑ Plant Allergies? _____________________

❑ Drug Allergies? _______________________________

❑ Animal Allergies? ___________________

❑ Other? ______________________________________

❑ Reactions? _________________________

Date of last tetanus shot __________________

Physical Conditions: ______________________________

Medications and Dosages: ____________________________________________________________________

List Any Restrictions (i.e.: activities, foods) _____________________________________________________

I/we the parent(s)/legal guardian(s) of the above named child do hereby delegate to the Leadership of CHIEF Basketball a "Power of

Attorney" for the above named child for the purpose of having custody of our child and my/our consent to any needed

emergency/medical treatment of said child.

In the event that I cannot be reached in an emergency between the dates specified on this form, I hereby give my permission to the

physician or dentist selected by the CHIEF Basketball Leadership to hospitalize, to secure proper treatment, and/or order an injection,

anesthesia, or surgery for my son or daughter as deemed necessary.

I understand that, if I have medical insurance, my carrier will be billed for medical charges in the case of illness or injury while my

son or daughter is on this sports related activity.

I understand that every activity sponsored by CHIEF Basketball is carefully planned and adequately supervised by mature adults.

However, even with the best of planning and precaution, unforeseen events can occur. By signing this form, as parent/guardian, I

agree to assume and accept all risks and hazards inherent in this church-related special activity. I also agree not to hold CHIEF

Basketball or its volunteer leaders liable for damages, losses, or injuries to the person or property undersigned. As parent/guardian, I

understand that I am signing for the minor named on this form and the signature(s) are to provide the power of attorney, the medical

release, and the liability release.

Signature of parent/guardian

Date:

Temporary Power Of Attorney And Medical And Liability Release Form

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