Waiver of Liability
I give permission for my child, named below, to participate in the Trashketball Tournament on Sunday March 4th, 2018 at Central Bucks East High School. I release and hold harmless Covenant Church, it’s staff and volunteers from responsibility and liability in the event of any injury or illness that my child may incur during the event. I expect to be contacted as soon as possible should any injury or emergency occur. In the event that I cannot be reached, I authorize Covenant Church Staff or adult volunteer to consent to any medical treatment including but not limited to examinations, surgery, hospitalization, diagnostic testing and imaging, casting or any other medical procedure or diagnostic process deemed necessary and appropriate to the condition by a physician, surgeon, emergency medical personnel or dentist licensed to practice in the state where treatment is being administered. Student Name: ___________________________________________________________________ Grade and School: ________________________________________________________________ Emergency Contact Phone #(s): ______________________________________________________ Family Doctor (Name and Phone #): __________________________________________________ Insurance Provider and Policy # : _____________________________________________________ _______________________________________________________________________________ Allergies (Food or Otherwise?): ______________________________________________________ EPI Pen or Other Medications that may be required during the course of the event? _____________ _______________________________________________________________________________
Parent or Legal Guardian Signature: __________________________________________________ Date: ________________________ Questions? Give us a call at 267-880-3713 or send an email to
[email protected]
