Parent Release Form

Parent/Guardian Consent and Medical Release

*Please send copy of both sides of your health insurance card to lin@sephlin.com

Recognizing the possibility of injury or illness, and in consideration for Sephlin Foundation and members of Sephlin Foundation accepting my son/daughter as a participant in the programs and activities of Sephlin Foundation and its members (the “Programs”), I consent to my son/daughter participating in the Programs. Further, I hereby release, discharge, and otherwise indemnify Sephlin Foundation, its member organizations and sponsors, their employees, associated personnel, and volunteers, including the owner of courts, fields and facilities utilized for the Programs, against any claim by or on behalf of my participant son/daughter as a result of my son’s/daughter’s participation in the Programs and/or being transported to or from the Programs. I hereby authorize the transportation of my son/daughter to or from the Programs. My player son/daughter has received a physical examination from a licensed medical doctor and
has been found physically capable of participating in such activities. I have provided written notice, which is submitted in conjunction with this release and attached hereto, setting forth any specific issue, condition, or ailment, in addition to what is specified above, that my child has or that may impact my child’s participation in the Programs. I give my consent to have an athletic trainer and/or licensed medical doctor, or dentist provide my son/daughter with medical assistance and/or treatment and agree to be financially responsible for the reasonable cost of any such assistance and/or treatment.

Child's Full Name

Date of Birth

Gender

Street Address

City

State

Zip/Postal Code

Country

Father's First Name

Father's Middle Name

Father's Last Name

Father's Phone Number (Primary)

Father's Phone Number (Work)

Father's Phone Number (other)

Mother's First Name

Mother's Middle Name

Mother's Last Name

Mother's Phone Number (Primary)

Mother's Phone Number (Work)

Mother's Phone Number (other)

Emergency Contact First Name (when parents can't be reached)

Emergency Contact Last Name (when parents can't be reached)

Emergency Contact Phone Number (when parents can't be reached)

Relationship

2nd Emergency Contact First Name (when parents can't be reached)

2nd Emergency Contact Last Name (when parents can't be reached)

2nd Emergency Contact Phone Number (when parents can't be reached)

Relationship

Allergies

Other Medical Conditions

Participant's Physician

Physician's Phone Number

Medical and/or Hospital Insurance Company

Policy Holder

Policy Number

Group Number

Phone Number

Parent/Guardian Signature

Date

2 + 14 =