Emergency Release Form – Cleats vs. Cancer | High School Football Showcase

GENERAL INFORNATION

Students Legal Name *

First

Last

Birthdate *

mm/dd/yyyy

Grade

Freshmen
Sophomore
Junior
Senior

Sex *

Male
Female

Current Address *

Address Line 1

City

State

Zip Code

Student Email Address *

Parent Email Address *

Student Cell Phone # *

(1) Emergency Contact Name & Phone # *

(2) Emergency Contact Name & Phone # *

Father's Name & Phone #

Mother's Name & Phone #

Insurance Provider & Policy # *

Insured Employer

Family Physician & Phone # *

Existing medical conditions (medications-allergies-bee stings) *

MEDICAL HISTORY

Are you aware of any health problems? *

Yes
No
I do not know

Does the athlete take any medication? *

Yes
No
I do not know

Is athlete currently under medical care? *

Yes
No
I do not know

Does the athlete have any problems with vision (eyes)? *

Yes
No
I do not know

Has the athlete ever suffered a heart related illness (heat stroke)? *

Yes
No
I do not know

Does the athlete have a history of a concussion (getting knocked out)? *

Yes
No
I do not know

Does athlete have asthma (wheezing), hay fever or coughing spells after exercise? *

Yes
No
I do not know

Has the athlete ever broken a bone, had to wear a cast or had an injury to any joint? *

Yes
No
I do not know

Has it ever been necessary to restrict athlete’s activities for medical reasons? *

Yes
No
I do not know

Does athlete require special care for any reason? *

Yes
No
I do not know

Has the athlete ever had any surgeries? *

Yes
No
I do not know

Is the athlete diabetic? *

Yes
No
I do not know

Explain any YES answers in the space below

Signature *

PARENT’S STATEMENT I hereby give my consent for the above named student to compete in Cleats for Cancer, including practices for the event and I certify that the insurance information provided is accurate. Risk Warning: I realize that participating in competitive athletics may result in severe injury, including paralysis or death. It is understood Cleats for Cancer and or any Cleats for Cancer volunteers shares NO responsibility in the payment of medical fees incurred by injuries to participants in this event. Trainer Consent: I give my permission to the athletic trainer or other personnel to administer first aid, follow-up treatment and rehabilitation when appropriate in his or her professional judgment as approved by the consulting physician. Emergency Treatment: In the event of an accident or emergency, I give my permission for the school authorities to transport my child to any available doctor or hospital or request their services.

Date *