SHOOTERS BASKETBALL CLUB
(Please print, fill-out, and bring to tryouts)
 

EMERGENCY MEDICAL RELEASE AND LIABILITY WAIVER

PLAYERS NAME ____________________________ BIRTHDATE________________

STREET ADDRESS ______________________ CITY ____________ ZIP __________
 
HOME PHONE ____________________________________

EMERGENCY INFORMATION 

FATHER’S NAME ______________________________ CELL #________________

MOTHER’S NAME _____________________________ CELL # ________________
 
IN AN EMERGENCY WHEN PARENT/GUARDIAN CANT BE REACHED, PLEASE CONTACT THE FOLLOWING :

NAME _______________________________ PHONE # ______________________  

 
ALLERGIES _________________________________________________________

OTHER MEDICAL CONDITIONS ________________________________________

PHYSICIAN ______________________________ OFFICE# ___________________

MEDICAL/HOSPITAL INSURANCE CO ___________________________________ 
PHONE___________________

POLICY HOLDER’S NAME ___________________________ 
POLICY NUMBER __________________________________

THIS AUTHORIZATION FOR MEDICAL TREATMENT MUST BE COMPLETED BEFORE PARTICIPATION CAN BEGIN.  TREATMENT FOR INJURY WILL BE BASED ON INFORMATION PROVIDED HEREIN.

I, the undersigned (if player is 18 yrs or older), or parent/guardian of the above listed minor applicant/participant, acknowledge and fully understand that each applicant/participant will be engaging in activities that involve serious risk of injury, including permanent disability or death, and severe social and economic losses which might result not only from their own actions, inactions or negligence, but also from others, the rues of play, the condition of the premises or of any equipment used and further, that there may be other unknown risks not reasonably foreseeable at this time, assume all the forgoing risk and accept personal responsibility for the damages following such injury, permanent disability or death, hereby release, discharge, covenants not to sue and/or otherwise indemnify the Southside Shooters Basketball Club, Inc., its affiliated organizations and sponsors, their coaches, managers, employees, and associated officers, personnel, agents, directors including the owners and leasers used to conduct the event, all of which are herein after referred to as ‘releasees’ from any and all liability to each othe undersigned, his/her heirs, their next of kin, for any and all against any claim by or on behalf of the applicantas a result of the applicant’s participation in the programs, and being transported to and from the same, which transportation I hereby authorize.The applicant/participant has received a physical examination by a physician and has been found physically capable of participating fully in the program.  I hereby give my consent to have an athletic trainer, coach and/or doctor of medicine or dentistry or associated personnel to provide the applicant/participant with medical assistance and/or treatment and agree to be financially responsible for such assistance or treatment.  I also agree to save and hold harmless and indemnify each and all parties herein referred to above as releasees from all liability, cost, claim, or damage whatsoever, including loss of life and damage to property, which may be imposed on said releasees because of any defect in or lack of such capacity to so act or caused or alleged to be caused in whole or in part by the negligence of the releasees.  I have read the above waiver/release and understand that I (we) have given up substantial rights by signing this release and sign below voluntarily.
  

PARENT SIGNATURE__________________________________ DATE__________________

PLAYER SIGNATURE__________________________________ DATE___________________