Chad Moeller Baseball
This MEDICAL HISTORY FORM must be completed/read annually by a parent (or Guardian) and player in order for the player to participate in this year's activities. These questions are designed to assist a doctor in case of emergency medical attention.
It is understood that even though protective equipment is worn by the athlete, whenever needed, the possibility of an accident still remains. Neither Chad Moeller Baseball, Team Dinger, nor the high school nor team or its members or coaching staff assumes any responsibility in the case an accident occurs.
If, in the judgment of any representative of the team or league, the above player should need immediate care and treatment as a result of any injury or sickness, I do hereby request, authorize, and consent to such care and treatment as may be given said student by any physician, trainer, nurse, school representative or coach. I do hereby agree to indemnify and save harmless the school and any school/ team/any member of the coaching staff or hospital representative from any claim by any person on account of such care and treatment of said student.
If, between this date and the beginning of athletic competition, any illness or injury should occur that might limit this player’s participation, I agree to notify the team’s authorities of such illness or injury.
I hereby state that, to the best of my knowledge, the above questions are complete and correct.
I give permission for any and all medical attention to be administered to my child (Name listed below), in the event of accident, injury, sickness, etc. under the direction of the person(s) listed below, until such time as I may be contacted. I also assume the responsibility for the payment of any such treatment. The release is effective for the period of one year from the date given below.
In case I cannot be reached, any of the following persons is designated to act on my behalf:
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