Eau Claire Husky Hoops

Eau Claire Husky Hoops Informed Consent, Release Form

* Child's Name:

* Child's Grade:

I hereby give permission for the above child to participate in the Eau Claire Husky Hoops boys' basketball program for the 2018-19 basketball season.

In case of emergency involving my son, I understand every effort will be made to contact me. In my absence, I authorize the coaches and Directors to use their judgment concerning medical care in case of illness or injury during practice or
games. I release the Eau Claire Husky Hoops organization, board of directors, coaches and coordinators from any and all claims or liability arising from my son’s participation in the program.

My child and I agree to abide by the respective codes of conduct for players and their parents or guardians as well as all practice requirements for the duration of the season. The above named player resides or attends school within the Eau Claire North High School district. We realize that failure to follow this agreement can result in removal from the Husky Hoops program.

* Date of Birth:

* School:

* Medical Insurance Company:

* Policy Number:

* Primary Physician:

* Hospital Preference:

* Current Medications:

* Allergies and medical conditions:

* Parent 1 name:

* Address:

* Preferred Phone:

* E-mail:

Parent 2 Name:

Address:

Preferred Phone:

E-mail:

* Emergency contact person:

* Relationship:

* Phone:

Eau Claire Husky Hoops may use a photograph that includes my son on promotional media.

* Person submitting form:

* Relationship:

* Date:

* Send a copy of the confirmation to this email address:

* indicates required fields

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Eau Claire Husky Hoops Informed Consent, Release Form