GJ Blackout Medical Release & Participation

As a parent or legal guardian of:

Name

First

Last

Authorization of Participation

I authorize their participation in the basketball program conducted by GJ Blackout. I understand that basketball is a contact sport and injuries can and sometimes do occur during practices and games. By authorizing participation, I assume the risk of injury to my child and hereby release the GJ Blackout organization, its board members, administration, coaches and other agents from any and all claims arising from the participation of my child in the basketball program and waive all claims hereto.

Electronic Signature Statement

I acknowledge electronic signatures contained in this form are valid authorization in lieu of my physical signature.

EMERGENCY MEDICAL TREATMENT

Authorization of Emergency Medical Treatment

I authorize my child’s coach and/or sponsor to secure medical treatment in the event of an injury or accident. Coaches and/or sponsors will attempt to contact parents or guardians as to the injury and treatment of your child. I acknowledge the electronic signature below is a valid authorization in lieu of my physical signature.

Parent/Guardian Name:

First

Last

Address:

Street Address

Apartment / Unit #

City

State/Province

Zip/Postal

Home Phone:

Work Phone:

Cell Phone:

Email:

Insurance Company:

Policy #:

Parent / Guardian Signature TO AUTHORIZE EMERGENCY MEDICAL TREATMENT:

Clear

REJECTION OF AUTHORIZATION OF HEALTH CARE

Parents who do not want to give their coach the authority to act on their behalf in case of an emergency, please sign below.

Authorization of Emergency Medical Treatment

I reject authorization of health care. I acknowledge the electronic signature below is a valid authorization in lieu of my physical signature.

Name of Player:

Date

Parent / Guardian Signature IF REJECTING AUTHORIZATION OF HEALTH CARE

Clear

In the event the parent or legal guardian cannot be reached please name the emergency contact.

Name of Emergency Contact:

First

Last

Relation:

Emergency Contact Phone:

GJ Blackout Waiver

GJ Blackout Medical Release & Participation

EMERGENCY MEDICAL TREATMENT

REJECTION OF AUTHORIZATION OF HEALTH CARE

In the event the parent or legal guardian cannot be reached please name the emergency contact.

GJ Blackout

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