We, the parents of the participants, a minor, do herby authorize the coaches, assistant coaches, or parents of team members acting in the capacity of activity supervisor as agents for the listed to consent to medical, surgical, or dental examination, on an emergency basis.
In case of emergency, I/We authorize treatment and/or care of registered player at any hospital. If there is an emergency and I/we can not be reached, emergency contacts have been identified on this form.
Warning: child may be injured while playing recreation ball.
WAIVER OF LIABILITY AND DISCLAIMER
To induce the Church Hill-Mt. Carmel-Surgoinsville Recreation to accept registration and permit participation in the youth recreation league by individual named above, I, the parent or guardian of said individual, hereby give my consent and agree to release, indemnify, and hold harmless church Hill-Mt. Carmel-Surgoinsville Recreation, its officials, coaches, representatives director, and commissioners from any claim arising out of injuries or conditions caused by our/my refusal to seek or obtain available medical treatment for the child.
Legal authorization is acknowledge by submission of this form to the recreation department.
Birth certificate must be provided before child will be allowed to participate.