Emergency Release Form

GENERAL INFORNATION

mm/dd/yyyy

MEDICAL HISTORY

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.
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Mailing AddressPO BOX 88194 Seattle, WA 98138

Cleats vs Cancer is incorporated in Washington State in the Corporations & Charities Division and recognized by the State of Washington Secretary of State Department, as a nonprofit organization.  The U.S. Department of the Treasury Internal Revenue Service (IRS) also recognizes Cleats vs Cancer as a nonprofit organization. The Cleats vs Cancer logo is federally trademarked by the U.S. Patent and Trademark Office.

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