Legacy Baseball and Softball Club, Inc

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Legacy Baseball and Softball Club Medical Release Form

PLAYER INFORMATION

* First Name:

* Last Name:

Street:

City:

State:

Zip Code:

Home Phone:

Email:

Gender:

Grade:

PARENT/GUARDIAN #1

Firstname:

Lastname:

EMail:

Home Phone:

Work Phone:

Cell Phone:

PARENT/GUARDIAN #2

Firstname:

Lastname:

Email:

Home Phone:

Work Phone:

Cell Phone:

MEDICAL/EMERGENCY CONTACT INFORMATION

Emergency Contact:

Phone:

Relationship to Player:

Insurance Carrier:

Policy #:

Physician's Name:

Physician's Phone:

Is participant taking any medications or have a condition that may affect participant?s safety or performance in the activity?:

Yes

Are there any medical or health factors or conditions that might affect participant?s performance in activity?:

Yes

WAIVER INFORMATION

In case of injury or emergency, I for myself and/or participant (if participant is minor/child), and my personal representatives, heirs and assigns, (severally and collectively ?I?) for this registration form) give permission for an activity representative to call 911 and transport participant to a hospital. I shall inform the Club Board of Directors, in writing, of any medical or health conditions of participant that occurs or develops and which could affect participant?s safety, performance or participation in or throughout the activity.

I hereby confirm participant is in good health and able to participate in the activity. Also, I have been advised to consult with a licensed physician prior to participation in the activity. I acknowledge the activity may involve exposure to communicable diseases, apparent and inherent risks, dangers of bodily injury or death and damage to property. I fully accept and acknowledge the activities may involve risks, and I hereby assume all dangers and risks associated with participating in the activity and will be responsible for the same. I further understand that concussion information is available at www.cdc.gov/concussion.

I acknowledge that Legacy Baseball and Softball Club, Inc, and their respective employees, directors, officers, volunteers, members and any other participant, entity, party or person involved in any regard with the Activity or the Activity premises and their respective agents, personal representatives, heirs, employees, contractors, successors and assigns (each an activity representative and collectively the ?activity representatives?), shall not be responsible or liable in any regard or manner for any and all property damage or illness or bodily injury (including serious physical injury or even death) incurred by participant or any party related thereto, as a result of his/her participation in the activity.

I have read, fully understand, and hereby freely sign, approve of, and agree to the terms of this Medical Release Form. I hereby expressly and forever unconditionally release, discharge, covenant not to sue, waive my rights and remedies, and agree to hold harmless and indemnify the activity representatives from any and all claims, costs, demands, losses, damages, or expenses, and from all acts of active or passive negligence or other fault on the part of the activity representatives associated with, in whole or in part, participant?s involvement with the activity. I shall inform the Club Board of Directors in writing if any information provided in this Medical Release Form is incorrect or changes through the course of the activity.

I/we agree with the above *

* indicates required fields

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Legacy Baseball and Softball Club Medical Release Form