Medical Information
Athlete Name _________________________________________________________
Emergency Phone ______________________________________________________
Allergic Reactions______________________________________________________
Medication Currently Using _____________________________________________
Circle if known to have any of the following conditions:
Diabetes Epilepsy Hemophilia Heart Condition
Past illnesses or other information that would be useful in the event that treatment is necessary: _____________________________________________
Emergency Medical Authorization: I am aware of the risks, hazards and inherent dangers that may arise due to my child’s participation in the Roby Stahl’s Striker School, LLC being held at the Town and Country Sports Complex ( collectively referred to as “Roby Stahl/TC” in consideration for being allowed to participate in said activities, I herby release waive and discharge Roby Stahl's Striker School, LLC and Town and Country, its instructors, agents and employees from every claim, liability or demand of kind sustained, whether caused by the negligence of Roby Stahl/TC or otherwise. This release shall be binding upon any heirs, administrators, executors and assigns of mine.
I further agree to indemnify Roby Stahl/TC from any loss, liability, damage or cost it may incur due to my participation in said activity in any way whether caused by Roby Stahl/TC or otherwise.
In the event of illness or injury resulting or arising directly or indirectly out of said activity, I herby give my consent and authorization for (1) the administration of emergency first aid care and the treatment at the scene of an emergency by staff members or volunteers of Roby Stahl/TC or (2) the administration of any treatment deemed necessary by a licensed physician or dentist and (3) the transfer to any hospital deemed reasonably accessible. This authorization is not intended to cover major surgery unless the medical opinion of two (2) licensed physicians or dentists, concurring in the necessity for such surgery, are optioned prior to the performance of such surgery.
I further declare and warrant that I am covered by sufficient medical and dental insurance and that such insurance will remain in effect during my child’s participation in said activities.
______________________________________ _________
Signature of Parent or Guardian Date