Waiver of Liability Trasketball 2015


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Waiver of Liability 2015 Trashketball Tournament Sunday March 1, 2015 I give my permission for my child to attend and participate in the Trashketball event on Sunday, March 1, 2015 at Central Bucks East High School. I hereby release and hold harmless Covenant Church, its staff and volunteer workers, from responsibility and liability for an injury for illness that my child may sustain during this event. I expect to be contacted as soon as possible should injury occur. I authorize a Covenant Church staff member as an agent for me in the event I cannot be reached to consent to an x-ray examination; medical, dental or surgical diagnosis; treatment; and hospital car advised and supervised by a physician, surgeon or dentist (as appropriate) licensed to practice under laws of the state where services are rendered, either at a doctor’s office, any hospital, or at any clinic.

Student Name:___________________________________________ Emergency Phone #(s):____________________________________ Address:________________________________________________ Family Doctor:_____________________ Dr. Phone#____________ Medical Insurance Provider:_________________ Policy#________ Allergies:____________________________________________ ___ Parent/Guardian Signature:________________________________ Date:_________

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