Parental Permission And Medical Consent With Liability Release Form printable pdf download

LEADING EDGE ATHLETICS, LLC

PARENTAL PERMISSION AND MEDICAL CONSENT WITH LIABILITY RELEASE

Name: ________________________________________ Date of Birth: _______________

Address: _________________________________________________________________

City: _______________________________ State: ______ Zip: ______________________

The undersigned(s) being the lawful parent(s) and/or guardian(s) of the above child (the

"Child"), hereby consents to the participation by the Child in lacrosse practices games,

tournaments, clinics conducted by Leading Edge Athletics, LLC and to the participation of

the Child in all events relating to the activity from June 1, 2009 through December 31, 2009.

The undersigned hereby further authorize(s) any of the staff, employees, agents and

representatives of Organizer to provide for, approve and authorize any health care at any

hospital, emergency room, doctor’s office or other institution; employ any physicians, dentists,

nurses, or other person whose services may be needed for such health care; review and if

necessary disclose the contents of any medical records; execute any consent form required by

medical, dental or other health authorities incident to the provision of medical, surgical or dental

care to the child. Health care shall include but not be limited to the administration of anesthesia,

X-ray examination, performance of operations, diagnostic and other procedures.

If there is no medical emergency, the guardian will first use reasonable efforts to contact the

parent(s) and/or guardian(s) before administering or authorizing any treatment.

Notwithstanding other provisions in this Consent Form, Organizer shall not have the authority to

withhold or withdraw life-sustaining procedures for the Child.

The undersigned assume(s) all risk of injury or harm to the Child associated with participation in

the Activity and agree(s) to releases, indemnify, defend and forever discharge the Organizer and

its staff, employees and agents (collectively the "Organizer") of and from all liability, claims,

demands, damages, costs, expenses, actions and causes of action (collectively the "Claims") in

respect of death, injury, loss or damage to the Child or by the Child, howsoever caused, arising

or to arise by reason of or during the Child's participation in the Activity.

This Consent Form may be revoked at any time before the expiration date with written notice to

Organizer.

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___________________________

Signature of Parent

Date

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___________________________

Signature of Parent

Date

Parental Permission And Medical Consent With Liability Release Form