Ana səhifə

Medical release


Yüklə 6.58 Kb.
tarix08.05.2016
ölçüsü6.58 Kb.
BRAVO ALL-STARS

Birthday Party
MEDICAL RELEASE

Waiver Form

Child’s Name: _________________________________Female:______Male:_________


Address: ________________________________________________________________
City: __________________ State: __________Zip: _______Birthdate:_______________
Parents Name: ___________________________________________________________
Parent’s Cell #’s__________________________________________________________
In Case of an Emergency, :(other than parent):Name:______________________Cell #:________________
I, the undersigned, hereby state that I am the parent/legal guardian of the Participant listed above and that I give permission for him/her to attend and/or participate in this event directed by Bravo All-Stars. I understand that there is a risk that the Participant may occur or suffer illness, personal injury or other damages while attending and/or participating in such events. In consideration of the Participant being permitted to attend and/or participate in this event directed by Bravo All-Stars, I on behalf of myself and the Participant, waive, release, and forever discharge any and all rights and claims for damages that may arise now or in the future against Bravo All-Stars facilities, employees, agents, and for any personal injury, illness, or damages that the Participant or I may occur or suffer as a result of Participant’s attendance or participation in this event directed by Bravo All-Stars.

I acknowledge that I will be responsible for paying for any medical treatment that the Participant may receive as a result of injuries or illness suffered during his/her attendance and/or participation in this event directed by Bravo All-Stars. Should the Participant be injured or become ill during his/her attendance and /or participation in this event directed by Bravo All-Stars, and I am not immediately available, I authorize Bravo All-Stars to seek emergency medical attention for the Participant. Transportation, if needed will be to Winchester Hospital unless otherwise stated.


PHYSICAL INFORMATION: Please list any current or previous accidents, illness, or physical limitations that would stop or prevent your registered child from participating in the above program, otherwise state “NONE”
Medications: __________________________Allergies:_________________________________________
Any prior Medical Conditions? ____________________________________________________________
Physical Limitations or situations? Please state NONE if applicable: _______________________________
______________________________________________________________________________________

_____________________________________________________ ___________________________



PARENTS SIGNATURE DATE

891 Woburn St. Unit 2, Wilmington, Mass. 01887 nicole@bravoallstarz.com 978-658-9467


Verilənlər bazası müəlliflik hüququ ilə müdafiə olunur ©anasahife.org 2016
rəhbərliyinə müraciət