** Print out and bring completed form to tryouts **

 

SPARTANS HOCKEY CLUB

MEDICAL AUTHORIZATION & INDEMNIFICATION AGREEMENT

 

 

 

Player Name ________________________________           Date of Birth _________________

 

 

 

Parents/Guardian Names ________________________________________________________

 

 

 

Home Phone(s) _____________________                              ____________________________

 

 

 

Cell Phone(s) _______________________                              ____________________________

 

 

 

Emergency Contact Name  _____________________  Relation to Skater __________________

 

 

 

Emergency Contact Phone(s) _______________________________

 

 

Medical Authorization

 

            I, parent or legal guardian of the above named player, do give my consent and approval to any director, officer, head coach, assistant coach, or team manager of the Spartans Hockey Club (“SHC”), an Illinois not-for-profit corporation to authorize and approve any reasonably necessary medical or surgical treatment, including hospital care, diagnostic examinations or tests, in the event that the above named player is injured while participating in or attending any activities operated or sponsored by the SHC. This consent and authorization is valid only if, after reasonable effort has been made, the parent or legal guardian of the above named player cannot be reached to give express instructions as to the care and treatment of the above named player.

 

            I agree to defend, indemnify and hold harmless from any liability for losses, claims, damages, costs and expenses (including attorney fees), the SHC and any director, officer, head coach, assistant coach, or team manager of the SHC with respect to any action taken on behalf of the above named player pursuant to this Medical Authorization.

 

 

 

 ____________________________________________                   ________________________                                                                                                                           

Signature of Parent or Guardian                                                         Date   

 

** Print out and bring completed form to tryouts **