Chesapeake Swim Club New Member Online Packet

CHESAPEAKE SWIM CLUB AUTHORIZATION/CONSENT FOR MEDICAL TREATMENT Updated 1/7/13CHILDS NAME: ______________________________ AGE: ______ DOB: __________ ADDRESS: _______________________________________________________________ PHONE: HOME ______________ WORK _______________ CELL ________________ PHYSICIAN ________________________________ PHONE ______________________ MEDICATIONS CURRENTLY BEING TAKEN __________________________________ KNOWN ALLERGIES ______________________________________________________ INSURANCE CARRIER/GROUP ______________________________________________ ADDRESS _________________________________________________________________ POLICY# ____________________________ GROUP # ____________________________ The above named child has our permission and consent to travel with CHESAPEAKE SWIM CLUB coach(es) and/or any official chaperones. We transfer parental responsibility of the above named child to CSC coach(es) and/or representative(s) for the duration of the meet(s) including travel to and from the meets. In the event of illness or injury to said child while traveling to or from or while participating in any such meet and after an attempt has been made to reach the parents or guardian of the child informing them of such illness or injury, the CSC coach (es) and/or designated representative(s) is/are authorized to contract for and to authorize the treatment by a medical doctor for said child as fully as we could do if present. Blood transfusions, if medically deemed advisable or necessary, ARE ARE NOT authorized as part of treatment. (please check one) In consideration of said child being permitted to travel with said party, and further consideration of the coaches and/or any official chaperones accompanying the team, we do hereby release and agree to hold harmless, unless negligence is involved, the Chesapeake SWIM CLUB, the coaches and official chaperones from any and all claims and liability, costs and expenses arising out of or resulting from the procurement of medical treatment for said child as aforementioned. This release also includes practices and CSC team sponsored activities in which parents are absent, should a medical emergency arise. Executed this ______________ day of ____________________, 20___ Signature of Father or Guardian ________________________________________ Signature of Mother or Guardian _______________________________________ Please list any other useful information or health concerns: __________________________________________________________________________________________ __________________________________________________________________________________________ 9